Category: Performance Improvement

Ten Indicators that your Company may have a Safety Culture Problem

December 11th, 2017 by


What puzzle pieces do you need to put in place to improve your safety culture?

A safety culture is difficult to measure, but there are some indicators that alert us to problems.

  1. There is no visible commitment from leadership.
  2. When there are competing priorities, safety comes in second.
  3. Workers feel uncomfortable reporting safety issues to their supervisors.
  4. Safety is viewed as more of a cost than an investment.
  5. Injuries and illnesses are sometimes swept under the rug.
  6. Safety issues are dealt with in an untimely and inefficient manner.
  7. Workers do not have the power or resources to find and fix problems as they see them.
  8. Managers are never seen on the shop floor with the workers.
  9. Safety is not part of the everyday conversation.
  10. Workers are blamed for accidents.

Do any of these sound familiar? If you identify problems like those listed above, you can improve your facility’s safety culture. We’re excited to welcome Brian A. Tink and Brian W. Tink back to the Global TapRooT® Summit to share their popular 2-day Pre-Summit course, “TapRooT® Analyzing and Fixing Safety Culture Issues.”

Click here to learn more about this course.

Register now for the 2-day course only (Febuary 26 and 27)

Register now for the 3-day Global TapRooT® Summit and this 2-day course (February 26 – March 2)

My 20+ Year Relationship with 5-Why’s

December 11th, 2017 by

I first heard of 5-Why’s over 20 years ago when I got my first job in Quality. I had no experience of any kind, I got the job because I worked with the Quality Manager’s wife in another department and she told him I was a good guy. True story…but that’s how things worked back then!

When I was first exposed to the 5-Why concept, it did not really make any sense to me; I could not understand how it actually could work, as it seemed like the only thing it revealed was the obvious. So, if it is obvious, why do I need it? That is a pretty good question from someone who did not know much at the time.

I dived into Quality and got all the certifications, went to all the classes and conferences, and helped my company build an industry leading program from the ground up. A recurring concept in the study and materials I was exposed to was 5-Why. I learned the “correct” way to do it. Now I understood it, but I still never thought it was a good way to find root causes.

I transferred to another division of the company to run their safety program. I did not know how to run a safety program – I did know all the rules, as I had been auditing them for years, but I really did not know how to run the program. But I did know quality, and those concepts helped me instill an improvement mindset in the leaders which we successfully applied to safety.

The first thing I did when I took the job was to look at the safety policies and procedures, and there it was; when you have an incident, “ask Why 5 times” to get your root cause! That was the extent of the guidance. So whatever random thought was your fifth Why would be the root cause on the report! The people using it had absolutely no idea how the concept worked or how to do it. And my review of old reports validated this. Since then I have realized this is a common theme with 5-Why’s; there is a very wide variation in the way it is used. I don’t believe it works particularly well even when used correctly, but it usually isn’t in my experience.

Since retiring from my career and coming to work with TapRooT®, I’ve had literally hundreds of conversations with colleagues, clients, and potential clients about 5-Why’s. I used to be somewhat soft when criticizing 5-Why’s and just try to help people understand why TapRooT® gets better results. Recently, I’ve started to take a more militant approach. Why? Because most of the people I talk to already know that 5-Why’s does not work well, but they still use it anyway (easier/cheaper/quicker)!

So it is time to take the gloves off; let’s not dance around this any longer. To quote Mark Paradies:
“5-Why’s is Root Cause Malpractice!”

To those that are still dug in and take offense, I do apologize! I can only share my experience.

For more information, here are some previous blog articles:

What’s Wrong With Cause-and-Effect, 5-Why’s, & Fault Trees

Comparing TapRooT® to Other Root Cause Tools

What’s Fundamentally Wrong with 5-Whys?

Not Near-Misses … They Are Precursors

December 5th, 2017 by

I had an epiphany today.

Have you ever noticed how management doesn’t take near-miss incidents seriously? They don’t see them as just one step away from a fatality?

I think part of the problem may be the terminology.

Near-miss just doesn’t sound very serious. After all … it was a miss.

But what if we called these incidents PRECURSORS.

A precursor tells you that something IS going to happen unless you change.

If management saw these incidents as an indicator that something was GOING TO HAPPEN, then, maybe, they would take action.

You may have already thought of this and changed the language that you use around incidents … but I haven’t seen the words PRECURSOR INCIDENTS used very often. Now may be the time to start.

One more thing … Precursor Incidents mean that incidents that could not cause an accident ARE NOT precursors. Thus, paper cuts are not precursors of amputations.

Therefore, we can stop wasting our time investigating incidents that will never cause a serious injury.

Just a thought…

Can Your Company Afford a Second Rate Improvement Program?

November 28th, 2017 by

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Sometimes it seems like management’s only objective is to cut costs. Can you produce excellence and record profits by cost cutting alone? Your company needs a world-class improvement program!

How do you get a world-class improvement program? As George Washington Carver said:

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Start where you are with what you have.
Make something of it and never be satisfied.

Have you become satisfied? Is it time to improve?

If you have never attended TapRooT® Training, start your improvement journey with a 2-Day TapRooT® Root Cause Analysis Course.

But most readers here have already learned the basics. They are ready for more. Perhaps a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. It’s a great place to learn to improve your skills to learn to investigate difficult, high-risk incidents.

If you are looking to go beyond just improving your own knowledge and you want to improve your company’s performance improvement initiatives, try reading our new book:

TapRooT® Root Cause Analysis Implementation – Changing the Way Your Company Solves Problems

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CLICK HERE to get your copy.

That’s a great start but there is even more…

Would you like to benchmark with industry leaders and learn from improvement experts from around the world? Attend the 2018 Global TapRooT® Summit. Many Summit attendees have explained that attending the Summit is a great way to learn from others and make your improvement program world-class.

People share their success and learn from others…

Many attend the pre-Summit advanced courses to get even more learning packed into their trip…

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Improvement is a never ending cycle of discovery. What are you doing to move the process forward?

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Is it time to make your improvement program world-class or are you settling for second rate performance?

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How Do You Get Started Using TapRooT® to Improve Your Root Cause Analysis?

November 21st, 2017 by

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Start where you are, with what you have.
Make something of it and never be satisfied.
George Washington Carver

When someone asks me where they should start when implementing TapRooT® to improve root cause analysis, my answer is ALWAYS:

It depends on where you are.

Your company vision makes all the difference in deciding what you need to do first to implement TapRooT® as you problem solving tool of choice.

What is your corporate vision? It is one of these three:

  • Blame Vision
  • Crisis Vision
  • Opportunity to Improve Vision

If you don’t know about these three types of “Vision,” read about them in the TapRooT® Root Cause Analysis Leadership Lessons book.

If your company looks for problems as an opportunity to improve, you are in luck! Your company has the Opportunity to Improve Vision and you have a high probability of success! You can begin with any of the “getting started” sections of the book, TapRooT® Root Cause Analysis Implemention – Changing the Way Your Company Solves Problems.

There are three main places to start that are described in the book…

Chapter 1 describes the most frequently used way to start using the TapRooT® Root Cause Analysis System: “Just Do It.” This is a fast way to see the benefits that TapRooT® Root Cause Analysis provides.

Chapter 2 describes incorporating the TapRooT® Root Cause Analysis Tools into an already existing improvement system. If you have implemented Lean, Six Sigma, TQM, RCM, TPM, ISO, Operational Excellence, Process Safety Management, Patient Safety, Behavior Based Safety, or HU, this might be the place that you choose to start implementing TapRooT®.

Chapter 3 describes a complete implementation of TapRooT® based on the best practices we have observed from TapRooT® Users from around the world. This guide to audit a “complete” implementation may seem complex. Perhaps that is why so many TapRooT® Users start with the simpler methods described in Chapters 1 and 2 and use Chapter 3 as their ultimate goal.

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Read TapRooT® Root Cause Analysis Implemention – Changing the Way Your Company Solves Problems and learn more about implementing TapRooT® at your site. Or give us a call at 865-539-2139 or contact us through our web site by CLICKING HERE to discuss your options.

But whatever you do … DON”T WAIT. Problems aren’t going to get any smaller while you wait to improve your root cause analysis.

Put your root cause analysis data to use

November 20th, 2017 by

 

“Just as the introduction of electricity shifted the world’s industrialized economies into higher gear a century ago, digital technologies are fueling economic activity today. This time, however, the transformation is unfolding exponentially faster.” from Digital America: A Tale of the Haves and Have Mores, McKinsey & Company

We live in an age of information, data is collected in evermore places and shared between people and machines in the IoT. Data collection and analysis is becoming easier and easier, with apps, new devices and software.

Still, in the construction industry 30% to 60% of contractors surveyed in the recent Construction Technology Report use manual processes or spreadsheets to manage takeoff, estimating, subcontractor prequalification, bids and data collection. Fewer than half of contractors responding to the survey use mobile apps for daily reporting, worker time entry, managing safety, or tracking job performance.

When it comes to investigating issues and doing root cause analysis, the TapRooT® approach yields effective and consistent results across different industries. For several years software has been available to support teams with their investigations. Now in it’s 6th version, the TapRooT® software offers the highest productivity. Charting incidents is easy, powerful tools assist with identifying Causal Factors and Root Causes, as well as with writing Corrective Actions.

New and improved graphing tools makes it easy to plot data, and trends can be better captured, over time. Watch this short video, or read more here. Stay tuned for updates about a future smart phone App.

#taproot_RCA

Five Trends that Will Impact Companies in Environment, Health and Safety in 2018

November 17th, 2017 by

As we approach 2018, now is a good time to look at some external trends to gauge what is coming down the pike. At System Improvements we recently fired up the crystal balls, and spotted five trends that will impact companies:

  • Proactive Safety Culture,
  • Reporting Capability
  • Focus on Prevention
  • Work force changes
  • Increased Drug Use

Let’s look at each of these.

Proactive Safety Culture: Executives continue to get more involved, safety is seen as an improvement opportunity and something to be managed, rather than a liability driven by chance or “workers unsafe actions”. Preventive methods will be used more, like work site evaluations, audits, functional job analysis, and ergonomics training. Instead of having impossible goals like “Zero Harm”, companies will set improvement KPIs, then investigate, track and trend incidents and near misses and put corrective actions in place

Reporting Capability: User- friendly software like TapRooT® and Enablon is available for capturing data and carrying out analysis. Mobile apps and devices like wearable technology enables rapid collection and dissemination of findings. Training is readily available to make sense of the data collected and empower the front line

Focus on Prevention: Companies take active steps to prevent injuries and promote health and safety. We will see more fitness and wellness initiatives but also focus on “intangible” issues like stress, fatigue and mental health. Companies out of line will face ever- increasing Workers Comp costs

Work Force Changes: The age distribution and values of workers are changing, with millennials entering the workforce. The shortage of skilled workers will get worse, and there will be more contract and temp workers. It will be important to involve all these groups in the EHSQ efforts. There will also be more lone and unsupervised workers, which makes behavior- based safety much more difficult to implement

Increased Use of Illegal and Legalized Drugs:  Serious safety, quality and environmental risk. Executives will have to find ways to manage the opioids cycle where injuries drive prescriptions and workers under the influence of opioids get injured again… In some jurisdictions legalization of marijuana is disqualifying a large share of the worker pool from safely operating vehicles, machinery and equipment. In the Hotels & restaurant industry, research found up to 19% of workers using drugs on a regular basis, a clear risk in e.g. kitchen areas. Alcohol will continue to be an issue, not least in Mining and Construction where up to a fifth of workers are estimated to be affected.

A good way to prepare for these trends is to do effective Root Cause Analysis. The TapRooT® methodology helps companies identify root causes of incidents, and put effective corrective actions in place. The process is also used for proactive audits, where issues can be nipped in the bud. Click here for more information: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training.

Is TapRooT® Root Cause Analysis a Tool or the Whole Toolbox?

November 14th, 2017 by

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I had a self-proclaimed root cause analysis expert tell me that investigators needed lots of “tools” in their root cause analysis toolbox. For most people that leads to the question:

How many tools do I need to learn?

When we started to develop TapRooT® back in the 1980’s, we thought we just needed a tool. We soon learned that we needed a toolbox. So we went to work finding, developing, and refining the best root cause analysis tools and adding them to our root cause analysis toolbox called the TapRooT® Root Cause System.

You might ask:

What’s in the toolbox?

The TapRooT® 7-Step Major Investigation Process from the book, Using TapRooT® Root Cause Analysis for Major Investigations, shows all the major tools in the right column.

SI Chart 7 StepMajorInvestigation

How can you learn these techniques and “fill your toolbox” with tools proven to be successful by TapRooT® Users from around the world? Attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Courses. See the locations and dates for our public courses around the world at:

http://www.taproot.com/store/5-Day-Courses/

But why should you learn these tools?

First, we spent decades of research and developing choosing, developing, and refining these techniques to make them the most successful root cause analysis toolbox in the world. See our user success stories at:

http://www.taproot.com/archives/category/success-stories?s=

The research and testing we performed showed us the limitations of some common root cause analysis tools that some experts try to teach and have trouble getting their students to achieve consistent results. We based our selection of techniques on human factors principles. This makes our system robust yet easy to use.

We also decided to limit the techniques we chose to those that you would really need. Most people don’t get tremendous amounts of experience performing root cause analyses. Thus, we wanted to minimize the training and practice required to use TapRooT®. We made it so that TapRooT® can be applied to low-risk incidents (simple incidents) or medium to high-risk incidents. In that way people get experience applying TapRooT® to simple incidents so that they are practiced using the techniques when something big happens (God forbid).

Also, we built human factors experts systems (AI) into the TapRooT® System to help investigators find the root causes of human errors and equipment problems.

Finally, do other root cause analysis systems provide this course guarantee:

Attend this course, go back to work, and use what you have learned to analyze accidents,
incidents, near-misses, equipment failures, operating issues, or quality problems.
If you don’t find root causes that you previously would have overlooked and
if you and your management don’t agree that the corrective actions that you recommend
are much more effective, just return your course materials/software
and we will refund the entire course fee.

That’s a powerful guarantee. And we can offer it because of the hundreds of thousands of people we have trained who apply TapRooT® sucessfully. We know you, too, will be successful.

Why not create your own toolbox?

You could duplicate our efforts, spend decades researching and perfecting your own toolbox of root cause analysis tools. Then you could develop training courses to teach what you learned. But guess what … your system still wouldn’t be as good as TapRooT®. Why? Because while you were doing your research, we would be improving. We constantly make the TapRooT® Books, Training, and Software better.

Besides the feedback we get from thousands of users and from classes we hold around the world, we have a TapRooT® Advisory Board that makes suggestions and reviews improvement ideas. This helps us keep making the best even better.

And one last advantage that we have … very talented instructors. We have 50 instructors at various locations around the world that have extensive experience teaching and using the TapRooT® System. And these instructors are constantly sharpening their skills. We have a link on our blog with a few profiles of our instructors but we are way behind on keeping it updated. This gives us something to improve!

If you want to learn more about TapRooT®, attend a class. Or at least see the About TapRooT® page on our web site.

More Proof that Hospitals Need to Improve Root Cause Analysis

November 6th, 2017 by

What would you think if your hospital received a “D” in a Leapfrog hospital rating? THIS ARTICLE points out three hospitals in the Atlanta area that received the worst Leapfrog scores.

My response would be that they need better root cause analysis. With advanced root cause analysis they would be finding the causes of infections, treatable complications, unnecessary blood clots, collapsed lungs, air or gas bubbles in the blood, and other preventable errors.

Effective root cause analysis is the basis for an effective performance improvement program. Without effective root cause analysis, a hospital is doomed to repeat their errors because they are guessing at solutions.

Want to find out more about the 5-Day Advanced Root Cause Analysis Training? See:

http://www.taproot.com/courses#5-day-root

Monday Accidents & Lessons Learned: Review of a Comprehensive Review

November 6th, 2017 by

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What will it take for the US Navy surface fleet (or at least the 7th Fleet) to stop crashing ships and killing sailors? That is the question that was suppose to be answered in the Comprehensive Review of Recent Surface Force Incidents. (See the reference here: Comprehensive+Review_Final.pdf). This article critiques the report that senior Navy officials produced that recommended changes to improve performance.

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If you find yourself in a hole, stop digging!!
Will Rogers

The report starts with two and a half pages of how wonderful the US Navy is. The report then blames the crews for the accidents. The report stated:

In each incident, there were fundamental failures to responsibly plan, prepare and execute ship activities to avoid undue operational risk. These ships failed as a team to use available information to build and sustain situational awareness on the Bridge and prevent hazardous conditions from developing. Moreover, leaders and teams failed as maritime professionals by not adhering to safe navigational practices.

It also blamed the local command (the 7th Fleet) by saying:

Further, the recent series of mishaps revealed weaknesses in the command structures in-place to oversee readiness and manage operational risk for forces forward deployed in Japan. In each of the four mishaps there were decisions at headquarters that stemmed from a culturally engrained “can do” attitude, and an unrecognized accumulation of risk that resulted in ships not ready to safely operate at sea.

Now that we know that more senior brass, the CNO, the Secretary of the Navy, the Secretary of Defense, the Congress, or the President (current or past) have nothing to do with the condition of the Navy, we can go on to read about their analysis and fixes.

The report states that individual root cause analysis of US Navy crashes were meant to examine individual unit performance and did NOT consider:

  • Management Systems (Doctrine, Organization, Leadership, Personnel)
  • Facilities and Material
  • Training and Education

The “Comprehensive Report” was designed to do a more in-depth analysis that considers the factors listed above. The report found weaknesses in all of the above areas and recommended improvements in:

  • Fundamentals
  • Teamwork
  • Operational Safety
  • Assessment
  • Culture

The report states:

The recommendations described in this report address the skills, knowledge, capabilities, and processes needed to correct the abnormal conditions found in these five areas, which led to an accumulation of risk in the Western Pacific. The pressure to meet rising operational demand over time caused Commanders, staff and crew to rationalize shortcuts under pressure. The mishap reports support the assertion that there was insufficient rigor in seeking and solving problems at three critical stages: during planning in anticipation of increased tasking, during practice/rehearsal for abnormal or emergency situations in the mishap ships, and in execution of the actual events. This is important, because it is at these stages where knowledge and skills are built and tested. Evidence of skill proficiency (on ships) and readiness problems (at headquarters) were missed, and over time, even normalized to the point that more time could be spent on operational missions. Headquarters were trying to manage the imbalance, and up to the point of the mishaps, the ships had been performing operationally with good outcomes, which ultimately reinforced the rightness of trusting past decisions. This rationalized the continued deviation from the sound training and maintenance practices that set the conditions for safe operations.

The report mentions, but does not emphasize, what I believe to be the main problem:

The findings in chapters four through eight and appendix 9.10 underscore the imbalance between the number of ships in the Navy today and the increasing number of operational missions assigned to them. The Navy can supply a finite amount of forces for operations from the combined force of ships operating from CONUS and based abroad; this finite supply is based both on the size of the force as well as the readiness funding available to man, train, equip and sustain that force. Headquarters are working to manage the imbalance. U.S. Navy ships homeported in the continental United States (CONUS) balance maintenance, training and availability for operations (deployments and/or surge); the Pacific Fleet is re-examining its ability to maintain this balance for ships based in Japan as well. Under the Budget Control Act of 2011 and extended Continuing Resolutions, the ability to supply forces to the full demand is – and will remain – limited.

The report does not say how many more ships the 7th Fleet or the US Navy needs.

The report also stated:

The risks that were taken in the Western Pacific accumulated over time, and did so insidiously. The dynamic environment normalized to the point where individuals and groups of individuals could no longer recognize that the processes in place to identify, communicate and assess readiness were no longer working at the ship and headquarters level.

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This could be used as a definition of normalization of deviation. To read more about this, see the article about Admiral Rickover’s philosophy of operational excellence and normalization of deviation by CLICKING HERE.

Normalization of deviation has been common in the US Navy, especially the surface fleet, with their “Git er Dun” attitude. But I’m now worried that the CNO (Chief of Naval Operation), who was trained as a Navy Nuke, might not remember Admiral Rickover’s lessons. I also worry that the submarine force, which has had its own series of accidents over the past decade, may take shortcuts with nuclear safety if the emphasis on mission accomplishment becomes preeminent and resources are squeezed by Washington bureaucrats.

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The military has been in a constant state of warfare for at least 15 years. One might say that since the peacekeeping missions of the Clinton administration, the military has been “ridden hard and put up wet” every year since that mission started. This abuse can’t continue without further detrimental effects to readiness and performance in the field.

The report summary ends with:

Going forward, the Navy must develop and formalize “firebreaks” into our force generation and employment systems to guard against a slide in standards. We must continue to build a culture – from the most junior Sailor to the most senior Commander – that values achieving and maintaining high operational and warfighting standards of performance. These standards must be manifest in our approach to the fundamentals, teamwork, operational safety, and assessment. These standards must be enforced in our equipment, our individuals, our unit teams, and our fleets. This Comprehensive Review aims to define the problems with specificity, and offers several general and specific recommendations to get started on making improvements to instilling those standards and strengthen that culture.

This is the culture for reactor operations in the Nuclear Navy. But changing a culture in the surface fleet will be difficult, especially when any future accidents are analyzed using the same poor root cause analysis that the Navy has been applying since the days of sail.

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After the summary, the report summarizes the blame oriented root cause analysis that I have previously reviewed HERE and HERE.

Another quote from the report that points out the flaws in US Navy root cause analysis is:

Leadership typically goes through several phases following a major mishap: ordering an operational pause or safety stand down; assembling a team to determine what happened and why; and developing a list of discrete actions for improvement. Causes are identified, meaningful actions taken, and there has been repeated near- term success in instilling improved performance. However, these improvements may only have marginal effect in the absence of programs and processes to ensure lessons are not forgotten. Still, all levels of command must evaluate the sufficiency of internal programs and processes to self-assess, trend problems, and develop and follow through on corrective actions in the wake of mishaps.”

Instead of thinking that the lessons from previous accidents have somehow been forgotten, a more reasonable conclusion is that the Navy really isn’t learning appropriate lessons and their root cause analysis and their corrective actions are ineffective. Of course, admitting this would mean that their current report is, also, probably misguided (since the same approach is used). Therefore they can’t admit one of their basic problems and this report’s corrective actions will also be short lived and probably fail.

The 33 people (a large board) performing the Comprehensive Review of Recent Surface Force Incidents were distinguished insiders. All had either previous military/DoD/government affiliations or had done contracting or speaking work for the Navy. I didn’t recognize any of the members as a root cause analysis expert. I didn’t see this review board as one that would “rock the boat” or significantly challenge the status quo. This isn’t to say that they are unintelligent or are bad people. They are some of the best and brightest. But they are unlikely to be able to see the problems they are trying to diagnose because they created them or at least they have been surrounded by the system for so long that they find it difficult to challenge the system.

The findings and recommendations in the report are hard to evaluate. Without a thorough, detailed, accurate root cause analysis of the four incidents that the report was based upon (plus the significant amount of interviews that were conducted with no details provided), it is hard to tell if the finding are just opinions and if the recommendations are agenda items that people on the review board wanted to get implemented. I certainly can’t tell if the recommended fixes will actually cause a culture change when that culture change may not be supported by senior leadership and congressional funding.

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One more point that I noticed is that certain “hot button” morale issues were not mentioned. This could mean that certain factors effecting manning, training time wasted, and disciplinary issues aren’t being addressed. Even mentioning an example in this critique of the report seems risky in our very sensitive politically correct culture. Those aboard ships know examples of the type of issues I’m referring to, therefore, I won’t go into more detail. If, however, certain issues won’t be discussed and directly addressed, the problems being created won’t be solved.

Finally, it was good to see references to human factors and fatigue in the report. Unfortunately, I don’t know if the board members actually understand the fundamentals of human performance.

For example, it seems that senior military leadership expects the Commanding Officer, the Officer of the Deck, or even the Junior Officer of the Deck to take bold, decisive action when faced with a crisis they have never experienced before and that they have never had training and practice in handling. Therefore, here is a simple piece of basic human factors theory:

If you expect people to take bold, decisive action when faced with a crisis,
you will frequently be disappointed. If you expect that sailors and officers
will have to act in a crisis situations, they better be highly practiced
in what they need to do. In most cases, you would be much better off to
spend time and energy avoiding putting people in a crisis situation.

My father was a fighter ace in World War II. One of the things he learned as he watched a majority of the young fighter pilots die in their first month or even first week of combat was that there was no substitute for experience in arial combat. Certainly early combat experience led to the death of some poor pilots or those who just couldn’t get the feel of leading an aircraft with their shots. But he also observed that inexperienced good pilots also fell victim to the more experienced Luftwaffe pilots. If a pilot could gain experience (proficiency), then their chances of surviving the next mission increased dramatically.

An undertrained, undermanned, fatigue crew is a recipe for disaster. Your best sailors will decide to leave the Navy rather than facing long hours with little thanks. Changing a couple of decades of neglect of our Navy will take more than the list of recommendations I read in the Comprehensive Review of Recent Surface Force Incidents. Until more ships and more sailors are supplied, the understaffed, undertrained, under appreciated,  under supported, limited surface force that we have today will be asked to do too much with too little.

That’s my critique of the Comprehensive Review. What lessons should we learn?

  • You need to have advanced root cause analysis to learn from your experience. (See About TapRooT® for more information.)
  • Blame is not the start of a performance improvement effort.
  • Sometimes senior leaders really do believe that they can apply the same old answers and expect a different result. Who said that was the definition of insanity?
  • If you can’t mention a problem, you can’t solve it.
  • People in high stress situations will often make mistakes, especially if they are fatigued and haven’t been properly trained. (And you shouldn’t blame them if they do … You put them there!)
  • Just because you are in senior management, that doesn’t mean that you know how to find and fix the root causes of human performance problems. Few senior managers have had any formal training in doing this.

Once you have had a chance to review the report, leave your comments below.

Navy Releases Reports on Recent Collisions and Provides Inadequate Information and Corrective Actions

November 2nd, 2017 by

Punish

At the end of the cold war, politicians talked of a “peace dividend.” We could cut back our military funding and staffing.

Similar action was taken by the USSR Government for the Soviet fleet. I watched the Soviet Fleet deteriorate. Ships weren’t maintained. Training was curtailed. What was the second best navy in the world deteriorated. I thought it was good news.

What I didn’t know was that our fleet was deteriorating too.

Fast forward to the most recent pair of collisions involving ships in the 7th Fleet (The USS Fitzgerald and the USS John S McCain). If you read the official report (see the link below) you will see that the Navy Brass blames the collisions on bad people. It’s the ship’s CO’s and sailors that are to blame.

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The blame for the ship’s leadership and crews includes (list shortened and paraphrased from the report above by me):

USS Fizgerald

  • The Officer of the Deck (OOD) and bridge team didn’t follow the Rules of the Road (laws for operating ships at sea).
  • The ship was going too fast.
  • The ship didn’t avoid the collision.
  • Radars weren’t used appropriately.
  • The lookout (singular) and the bridge team was only watching the port side and didn’t see the contacts on the starboard side.
  • The Navigation Department personnel didn’t consider the traffic separation lanes when laying out the proposed track for navigating the ship (and this should have been well known since this ship was leaving their home port).
  • The navigation team did not use the Automated Identification System that provides real time updates on commercial shipping positions.
  • The Bridge team and the Combat Information Center team did not communicate effectively.
  • The OOD did not call the CO when required.
  • Members of the Bridge team did not forcefully notify and correct others (including their seniors) when mistakes were suspected or noted.
  • Radar systems were not operating to full capability and this had become accepted.
  • A previous near-collision had not be adequately investigated and root causes identified by the ship’s crew and leadership.
  • The command leadership did not realize how bad the ship’s performance was.
  • The command leadership allowed a schedule of events which led to fatigue for the crew.
  • The command leadership didn’t assess the risk of fatigue and take mitigating actions.

NewImageFired (reassigned) CO of USS Fitzgerald

USS John S McCain

  • Then training of the helm and lee helm operators was substandard in at least part because some sailors were assigned temporarily too the ship and didn’t have adequate training on the differences in the ships rudder control systems.
  • The aft steering helmsman failed to verify the position of the rudder position on his console and made a bad situation worse.
  • Senior personnel and bridge watch standers on the USS John S McCain seemed to have inadequate knowledge of the steering control system.
  • The ship’s watch standers were not the most qualified team and Sea Detail should have been set sooner by the Commanding Officer.
  • The OOD and Conning Officer had not attended the navigation brief held the previous day that covered the risk of the evolution.
  • Five short blasts were not sounded when a collision was immanent giving the other ship a chance to avoid the collision.
  • The CO ordered an unplanned shift of the propulsion control from one station to another without clear notification of the bridge watch team. This order occurred in a shipping channel with heavy traffic.
  • Senior officers and bridge watch standers did not question the report of loss of steering by the Helmsman or pursue the issue to resolution.

NewImageCO & XO of USS John S McCain that were fired (reassigned).

That’s a significant blame list. Can you spot what is missing?

First, the factors that are listed aren’t root causes or even near-root causes. Rather they are Causal Factors and maybe a few causal categories.

Second, the report doesn’t provide enough information to judge if the list is a complete list of the Causal Factors.

Third, with no real root cause analysis, analysis of Generic Causes is impossible. Perhaps that’s why the is no senior leadership (i.e., the Brass – Admirals) responsibility for the lack of training, lack of readiness, poor material condition, poor root cause analysis, and poor crew coordination. For an idea about Generic Cause Analysis of these collisions and potential corrective actions, see: http://www.taproot.com/archives/59924.

Here is a short recreation of the USS Fitzgerald collision to refresh you memory…

The US Navy did not release the actual accident investigation report (the Command and the Admiralty investigations) because the Chief of Naval Operations, “… determined to retain the legal privilege that exists with the command Admiralty investigations in order to protect the legal interests of the United States of America and the families of those Sailors who perished.” I believe the release of the actual investigation reports has more to do with protecting Navy Admirals and an inadequate training and manning of US Navy ships than protecting the US Government legally.

It seems to me that the US Navy has sunk (no pun intended) to the same low standards that the Soviet Navy let their fleet deteriorate to after the cold war ended. Bad material condition, low readiness, and, perhaps, poor morale. And the US Navy seems to have the same “transparency” that the USSR had during the communist hay day.

But I was even more shocked when I found that these problems (Training, manning, material condition, …) had been noted in a report to senior US Navy leadership back in 2010. That’s right, military commanders had known of these problems across the fleet for seven years and DID NOT take actions to correct them. Instead, they blame the Commanding Officers and ship’s crews for problems that were caused by Navy and political policy. Here is a link to that report:

https://www.scribd.com/document/43245136/Balisle-Report-on-FRP-of-Surface-Force-Readiness

Why didn’t senior leadership fix the problems noted in the report? One can only guess that it didn’t fit their plans for reduced manning, reduced maintenance, and more automated systems. These programs went forward despite evidence of decreased readiness by ships in the fleet. A decreased state of readiness that led two ships to fatal collisions. This cutting of costs was a direct response to budget cuts imposed by politicians. Thus “supporting our troops” is too expensive.

It seems from the reports that the Navy would rather punish Commanding Officers and the ship’s crews rather than fix the fleet’s problems. No accountability is shared by the senior naval leadership that has gone along with budget cuts without a decrease in the operating tempo and commitments.

NewImageChief of Naval Operations who says these types of accidents should “never happen again.”

More blame is NOT what is needed. What is needed is advanced root cause analysis that leads to effective corrective actions. The report released by the Navy (at the start of this article) doesn’t have either effective root cause analysis or effective corrective actions. I fear the unreleased reports are no better.

What can we do? Demand better from our representatives. Our sailors (and other branches as well) deserve the budget and manning needed to accomplish their mission. We can’t change the past but we need to go forward with effective root cause analysis and corrective actions to fix the problems that have caused the decline in mission capabilities.

KISS and Root Cause Analysis

November 1st, 2017 by

I’ve heard many “experts” claim that you need to apply the KISS principle when it comes to root cause analysis. You may hear this too and I want you to understand where these experts lead many people astray.

First, what is KISS? Keep It Simple Stupid! The acronym implies that simple solutions are better solutions. And when simple solution work (are effective) KISS is a dream come true. But remember Einstein’s quote:

Make things as simple as possible, but not simpler.

So let’s start with some of the reasons that these experts say you need to use simple techniques and debunk or demystify each one. Here’s a list of common expert advice.

  1. It’s a waste of time to use full root cause analysis on every problem.
  2. People can’t understand complex root cause analysis techniques.
  3. Learning simple techniques will get people to start thinking deeper about problems.
  4. Simple is just about as good as those fancy techniques.
  5. Managers don’t have time to do fancy root cause analysis and they already know what is wrong.
  6. You can apply those complicated techniques to just the most serious accidents.
  7. The data from the simple investigations will help you identify the more complex issues you need to solve.

I see these arguments all the time. They make me want to scream! Let me debunk each one and then you too can dismiss these “experts” the next time they try one or more of these arguments on your management team.

1. It’s a waste of time to use full root cause analysis on every problem.

I actually sort of agree with this statement. What I don’t agree with is the answer they arrive at. Their answer is that you should apply some “simple” root cause analysis technique (let’s just say 5-Whys as an example) to “solve” these problems that don’t deserve a well thought out answer.

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First, what do I have against their ideas of simple root cause analysis? If you’ve been reading this blog for a while you know what I’m going the explain, so just skip ahead. For those who don’t know what’s wrong with most “simple” root cause analysis techniques, I would suggest start reading from the top of the links below until you are convinced that most expert advice about “simple” root cause analysis is root cause analysis malpractice. If you haven’t been convinced by the end of the links … perhaps you are one of the experts I’m talking about. Here’s the list of links:

What happens when root cause analysis becomes too simple? Six problems I’ve observed. 

An Example of 5 Whys – Is this Root Cause Analysis? Let Me Know Your Thoughts…

What’s Wrong with 5-Whys??? – Complete Article 

What’s Fundamentally Wrong with 5-Whys?

Teruyuki Minoura (Toyota Exec) Talks About Problems with 5-Whys

I believe that one of the biggest root cause analysis problems that companies face is that they are performing “root cause analysis” on problems that don’t need to be analyzed.  YES – I said it. Not every problem deserves a root cause analysis.

What problems don’t need to be analyzed? Problems that aren’t going to teach you anything significant. I call these “paper cut problems.” You don’t need to investigate paper cuts.

But some people would say that you do need to investigate every loss time injury and medical treatment case. Maybe … maybe not.

You do need to investigate an incident if it could have caused an outcome that you are trying to prevent and there are worthy lessons learned. Some medical treatment cases fall into this category. They got a cut finger but they could have lost their whole arm.

Two similar examples are provided in the book: Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents. One is a sprained ankle and one is a sprained wrist. Both came from falling down. One was judged worthy of a full but simple root cause analysis using the essential features of the TapRooT® Root Cause Analysis System. One was judged not worthy of a full investigation after a simple SnapCharT® was developed. Interested in how this works? Read the book. It’s only 100 pages long and seeing how to judge if a root cause analysis is worthwhile is worth it. (And you will learn how to apply TapRooT® simply to low-to-medium risk incidents.)

Once you know how to do a real “simple” investigation with an effective technique, you won’t need to do bad root cause analysis with an ineffective technique.

2. People can’t understand complex root cause analysis techniques.

I don’t know every “complex” root cause analysis technique but I do know that this statement does NOT apply to TapRooT®. Why? Because we’ve tested it.

One “test” was at a refinery. The Operation Manager (a good guy) thought that TapRooT® was a good system but wasn’t sure that his operators would understand it. We decided to run a test. We decided to teach a basic class to all his union stewards. Then refinery management did a focus group with the shop stewards.

I was one of the instructors and from the course examples that they analyzed, I knew that they were really enjoying finding real root causes rather than placing blame.

They did the focus group (with us in another room). I could hear what was going on. The first question the facilitator asked was: “Did you understand the TapRooT® Root Cause Analysis Technique?” One of the shop stewards said …

“If I can run a Cat Cracker I can certainly understand this! After all, it’s not rocket science!”

And that’s one of the great parts about TapRooT®. We’ve added expert systems for analysis of equipment and human performance problems, but we’ve kept the system understandable and made it easy to use. Making it seem like it isn’t rocket science (even though there is a whole bunch of science embedded in it) is the secret sauce of TapRooT®.

3. Learning simple techniques will get people to start thinking deeper about problems.

Learning to count is required before you learn calculus BUT counting over and over again does not teach you calculus.

If you don’t understand the causes of human performance problems, you won’t find the causes of the problems by asking why. And I don’t care how many times you ask why … it still won’t work.

For years we did a basic poll at the start of our 5-Day TapRooT® Advanced Root Cause Analysis Courses. We asked:

“How many of you have had any formal training in human factors or the causes of human error?”

Only about 2% of the attendees had ANY training on the causes of human error. But almost everybody that attended our training said that they had previously been assigned to find the causes of human errors. I wonder how well that went? (I can tell you from the student feedback, they said that they really DID NOT address the real root causes in their previous investigations.)

So, NO. Learning simple techniques DOES NOT get people to “think deeper” about problems.

4. Simple is just about as good as those fancy techniques.

NO WAY.

First, I’ve never seen a good example of 5-Whys. I’ve seen hundreds of bad examples that 5-Why experts thought were good examples. One “good example” that I remember was published in Quality Progress, the magazine from the American Society for Quality (ASQ). I couldn’t stand it. I had to write a reply. When I sent the letter to the editor, they asked me to write a whole article … so I did. To see the example and my article that was published in Quality Progress, see page 32 of the link below:

Under Scrutiny: A Critical Look at Root Cause Analysis.

Simple is not “almost as good” as real root cause analysis (TapRooT®). If you would like another example, see Chapter 3: Comparing the Results of a 5-Why Investigation to a Basic TapRooT® Investigation in the book, Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents.

That’s it – Case Closed. Those “simple” techniques are NOT just about as good as TapRooT® Root Cause Analysis.

5. Managers don’t have time to do fancy root cause analysis and they already know what is wrong.

Once again, I’m reminding of a saying:

Why is there never enough time to do it right,
but there is always enough time to do it over? 

How many times have I seen managers misdiagnose problems because they didn’t find the root causes and then have bigger accidents because they didn’t fix the near-misses and small accidents?

The percentage of managers trained in the causes of human error is very similar to the statistics I previously provided (2%). This means that managers need an effective root cause analysis technique … just like investigators need an effective technique. That’s why the standard corrective actions they use don’t solve the problems and we have accidents that happen over and over again.

So if you don’t have time, don’t worry. You will make time to do it over and over again.

That reminds me of a quote from a plant manager I knew…

“If we investigated every incident, we’d do nothing but investigate incidents!”

6. You can apply those complicated techniques to just the most serious accidents.

I’ve seen companies saving their “best” root cause analysis for their big accidents. Here are the two problems I see with that.

FIRST, they have the big accidents BECAUSE they didn’t solve the precursor incidents. Why? because they didn’t do good root cause analysis on the precursor incidents. Thus, applying poor root cause analysis to the lessor incidents CAUSES the big accidents.

SECOND, their investigators don’t get practice using their “best” root cause analysis techniques because the “most serious” incidents are infrequent. Therefore, their investigators get rusty or they never really develop the skills they need by using the techniques on smaller incidents that could give them practice.

The key here is to learn to use TapRooT® Root Cause Analysis to investigate smaller problems. And that’s why we wrote a book about using TapRooT® for simple incidents: Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents.

Don’t wait for big accidents to find and fix the causes of your biggest risks. Find and fix them when they give you warnings (the precursor incidents).

7. The data from the simple investigations will help you identify the more complex issues you need to solve.

Why do people think that analyzing lots of bad data will yield good results? I think it is the misconception about mathematics. A good formula doesn’t provide knowledge from bad data.

If you don’t really know how to analyze data, you should attend our pre-Summit course:

Advanced Trending Techniques

As W. Edwards Deming said:

“Without data, you’re just another person with an opinion.”

And if you know much about Deming, you know that he was very interested in the accuracy of the data.

If you aren’t finding the real root causes, data about your BAD ANALYSIS only tells you what you were doing wrong. You now have data about what was NOT the causes of your problems. Go analyze that!

So data from BAD simple investigations DOES NOT help you solve your more complex issues. All it does is mislead your management.

THAT’S IT. All the bad advice debunked. Now, what do you need to do?

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1. Read the book:

TapRooT® Root Cause Analysis Leadership Lessons

You will learn the theory behind performance improvement and you will be well on your way to understanding what management needs to do to really improve safety, quality, equipment reliability, and operational/financial performance.

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2. Read the book:

TapRooT® Root Cause Analysis Implementation

You will know how to implement a real, effective root cause analysis system for low-to-medium risk incidents as well as major accidents.

3. If you haven’t done it already, attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Courses. See the list of our upcoming public 5-Day TapRooT® Courses held around the world at this link:

http://www.taproot.com/store/5-Day-Courses/

And don’t take any more bad advice from experts who don’t know what they are talking about!

PS: If you have questions or want to discuss what you read in the books, contact me (Mark Paradies) at 865-539-2139 or by e-mail by clicking HERE.

How Good is Your TapRooT® Implementation?

October 24th, 2017 by

TapRooT® provides world-class root cause analysis. But did you know that your results can vary depending upon the goodness of your implementation of the TapRooT® System?

What causes the implementation to vary? Try these factors …

  • Need to improve clearly defined.
  • Senior management support achieved.
  • Written program plan approved by senior management.
  • Proactive improvements drive improvement success.
  • Use advanced root cause analysis for both reactive and proactive investigations.
  • Improvement accomplishments being communicated successfully.
  • Adequate budget/staffing for the improvement organization.
  • Training plan implemented.
  • Employees, supervisors, managers, and contractors/suppliers willingly participate in the program.
  • Software selected, customized, and implemented.
  • Performance measures and advanced trending techniques used by management to guide the program.
  • Organizational learning occurring by effective sharing of lessons learned.
  • Plan for continuous improvement of the program is followed.
  • Leadership succession plan established.
  • Rewards program being used effectively.

This list is provided as a checklist and explained in more detail in Chapter 3 of our new book:

TapRooT® Root Cause Analysis Implementation – Changing the Way Your Company Solves Problems

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CLICK HERE to order your copy.

One more idea you might want to pursue to improve your performance improvement program. Attend the 2018 TapRooT® Global Summit in Knoxville, TN, on February 26 – March 2! It’s a great place to keep up with the state of the art in performance improvement and network with industry leaders.

Start by attending one of our advanced courses on Monday & Tuesday:

  • TapRooT® Root Cause Analysis Training
  • Equifactor® Equipment Troubleshooting and Root Cause Analysis
  • Advanced Causal Factor Development Course
  • Advanced Trending Techniques
  • TapRooT® Analyzing and Fixing Safety Culture Issues
  • Risk Assessment and Management Best Practices
  • Getting the Most from Your TapRooT® VI Software
  • TapRooT® for AuditsTapRooT®
  • Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills
  • Understanding and Stopping Human Error

Then attend the Summit on Wednesday – Friday.

What’s on the agenda for the 2018 Global TapRooT® Summit? First, there are five keynote speakers:

  • Inquois “Inky” Johnson – Honor and Legacy
  • Vincent Ivan Phillips – How to Communicate Successfully
  • Dr. Carol Gunn – When Failure Becomes Personal
  • Mark Paradies – How Good is Your TapRooT® Implementation?
  • Mike Williams – Deepwater Horizon

Then there are nine different tracks that include 8 breakout sessions each. These tracks include:

  • Safety
  • Quality
  • Human Factors
  • Asset Optimization
  • Investigator
  • Patient Safety
  • TapRooT® Software
  • TapRooT® Instructor Recertification
  • Alternatives

See the Summit schedule at: http://www.taproot.com/taproot-summit/summit-schedule.

Book 2 in the New TapRooT® Series is Out. Do You Have Your Copy?

October 24th, 2017 by

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Would you like to improve your implementation of TapRooT®? Or are you just getting started and you are trying to decide where to start implementing TapRooT® to improve your root cause analysis?

You should read our new implementation book. CLICK HERE to order yours.

How Many Industries and How Many Countries is Your Root Cause Analysis System Used In?

October 17th, 2017 by

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I was talking to someone in the medical industry recently and they asked: “How many people in the medical industry use TapRooT®?”

I gave them several examples of major healthcare systems that use TapRooT® (including perhaps the world’s largest) but I thought … they asked the WRONG question.

The true value of a root cause analysis system is how many different places it is being used SUCCESSFULLY.

Note that this is not the same as if the system is used in a particular industry. It must be used successfully. And if it is used successfully in many other industries and many countries, that proves even more that the system is useful and will probably be useful when applied at your company.

Where is TapRooT® Root Cause Analysis applied successfully?

All over the world. On every continent but Antartica (we’ve never done a course there yet).

In what kind of industries? Try these:

  • Oil & Gas Exploration & Production
  • Refining
  • Chemical Manufacturing
  • Healthcare (Hospitals)
  • Pharmaceutical Manufacturing
  • Nuclear Power / Nuclear Fuels
  • Utilities
  • Auto Manufacturing
  • Aggregates
  • Mining (Iron, Gold, Diamonds, Copper, Coal, …)
  • Aluminum
  • Aviation (airlines and helicopters)
  • Shipping
  • Cosmetics
  • Construction
  • Data Security
  • Nuclear Weapons
  • Research Laboratories
  • Mass Transit
  • Regulatory Agencies
  • Prisons
  • Pulp & Paper
  • Engineering
  • Food & Drinks
  • Alchohol
  • Security
  • Recycling
  • Aerospace Manufacturing
  • Space Exploration
  • Pipelines
  • Agricultural Commodities
  • Steel
  • Forestry
  • City Government
  • General Manufacturing
  • Telecommunications
  • Airport Management

And that’s only a partial list.

Where can you read about the successful application of TapRooT® in some of these industries? Try these success stories:

http://www.taproot.com/archives/category/success-stories?s=

You will see examples of companies that saved lives, save money, prevent injuries, improved service, made work more productive, and stopped the cycle of blame and punishment.

The reason that TapRooT® is used by industry leaders is that it works in such a wide variety of industries in such a wide variety of countries.

But don’t just believe the industry leaders. Attend one of our GUARANTEED courses. Guaranteed? That’s right. Here is our guarantee:

  • Attend the course. Go back to work, and use what you have learned to analyze accidents, incidents, near-misses, equipment failures, operating issues, or quality problems. If you don’t find root causes that you previously would have overlooked and if you and your management don’t agree that the corrective actions that you recommend are much more effective, just return your course materials and we will refund the entire course fee.

It’s that simple. Try to find a money-back guarantee like that anywhere else. We are so sure of your success that we guarantee it.

Don’t wait. Register for one of our root cause analysis courses today. For a list of upcoming public courses, see:

http://www.taproot.com/store/Courses/

Why do people jump to conclusions?

October 10th, 2017 by

I see examples of people jumping to conclusions all the time. Instead of taking the time to analyze a problem, they suggest their favorite corrective action.

Why do they do this? I think it is because thinking is so hard. As Henry Ford said:

“Thinking is the hardest work there is, which is probably the reason why so few engage in it.”

Did you know that when you think hard, your brain burns more calories? After a day of hard thinking you may feel physically exhausted.

Neuroscientific research at Cal Tech has shown that the more uncertainty there is in a problem (a cause and effect relationship), the more likely a person is to use “one-shot” learning (jumping to conclusions). This simplification saves us lots of work.

What’s the problem with jumping to conclusions?

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And even more important than saving effort in the analysis is that if you jump to a conclusion, you get to recommend the corrective action that you wanted to implement all along. Skip all that hard work of proving what the cause was and the details of developing effective fixes. Just do what you wanted to do before the problem ever happened!

The next time you are tempted to jump to a conclusion … THINK!

Yes, real root cause analysis and developing effective fixes is harder than just implementing the fix that you have been wanting to try even before the accident, but getting to the root (or roots) of the problem and really improving performance is worth the hard work of thinking.

Why is Root Cause Analysis Applied Reactively More Than Proactively?

October 3rd, 2017 by

I attended an interesting talk on the brain yesterday and had a different perspective on why so many managers are reactive rather than being proactive.

What do I mean by that? Managers wait to start improvement efforts until after something BAD happens rather than using a constant improvement effort to avoid accidents before they happen.

What about “human nature” (or the brain or neuropsychology) makes us that way? It has to do with the strongest human motivators.

Dr. Christophe  Morin said that research shows that the most recognizable human emotions expressed in facial expressions are:

  • Fear
  • Sadness
  • Disgust
  • Anger
  • Surprise
  • Trust
  • Joy
  • Anticipation

What draws our attention the most? Fear and Anger.

It seems that fear and ager catch our eye because they could indicate danger. And avoiding danger is what our primitive brain (or reptilian brain) is wired to do. Before we have any conscious thought, we decide if we need to run or fight (the fight or flight reaction).

What does this have to do with root cause analysis and reactive and proactive improvement?

What happens after an accident? FEAR!

Fear of being fired if you did the wrong thing.

Fear of looking bad to your peers.

Fear of lower management getting a bad review from upper management if your people look bad.

And even fear of consequences (lower earnings and lower stock price and a reaction from the board) for upper management if the accident is bad enough and gets national press coverage.

Even senior managers may get fired after a particularly disastrous accident.

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So fear drives behavior in many cases.

Management is much more likely to spend valuable resources when they are afraid (after an accident) than before the accident when the fear is much less and the promise of improvement through proactive improvement may bring joy or the anticipation of success.

Thus, management focuses on root cause analysis for accidents and incidents rather than applying it to assessments, audits, and peer reviews.

Can your management overcome human nature and apply root cause analysis before an accident happens or do they have to wait for a disaster to learn? That may be the difference between great leaders and managers waiting to be fired.

Don’t wait. Start applying advanced root cause analysis – TapRooT® – today to prevent future accidents.

Attend one of our public 5-Day TapRooT® Advanced Root Cause Team Leader Courses to learn how to apply TapRooT® reactively and proactively.

Root Cause Audits Prevent Environmental Excursions

September 27th, 2017 by

All too often we hear stories about sewage spills and overflows, causing environmental damage and costing utilities and operators large fines. Sometimes the causes are catastrophic, like hurricanes. Unfortunately most of the time the reason is human performance and equipment malfunctions.

King County in Washington state recently had to pay a $361,000 fine for spilling 235 M gallons of sewage into the Puget sound. An investigation found the causes to be inadequate maintenance, reliability issues and lack of backup equipment. There was also a lack of employee training. Besides the fine, the county has to better monitor emergency bypasses, improve the reliability of equipment and upgrade alarm features in the plant control system.

A closer look reveals an inexpensive float switch was at the core of the issue. In the past this type of switch has repeatedly clogged, jammed and failed. To keep operations going, employees would bend the rod back in place instead of replacing it. All in all direct plant damage is $35M. This is the fourth environmental excursion since 2000, a cost which is not quantified, but large.

Another example is a recent 830,000 gallon sewage release into the Grand River in Ottawa County, Michigan, due to a power outage. Six months ago a broken 45 year old pipe caused a 2 M gallon spill at the same location. Replacement cost of the pipe is $5 M, funds are not available so the utility is patching and hoping for the best.

These are just two recent cases that would have benefited from doing a root cause audit. The methodology is similar to a root cause analysis, except of course it is done before any incident, and aims to find and fix the most impactful risks.

Steps in a root cause audit

Planning for and doing an audit typically follows the following pattern:

  1. Plan the audit, determine the process flow of problems that could turn into significant issues
  2. Perform the audit and record the findings
  3. Define the significant issues (similar to causal factors in a root cause analysis)
  4. Use the Root Cause Tree to analyze each significant issue
  5. Analyze any generic causes for each root cause
  6. Develop preventive fixes
  7. Get approvals, and implement the plan

When done, take a moment to recognize the people that helped, and do not forget to celebrate! To make things easier, it is worthwhile to learn from those that came before you!

We have long experience with investigations and corrective actions that work. A new book by Paradies, Unger & Janney “TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement” has practical check lists and advice on auditing and implementing corrective action. Read more and order your personal copy here: http://www.taproot.com/store/TapRooT-and-reg-for-Audits-Book-Set.html

Per Ohstrom is Vice President of Sales at System Improvements, Inc. #TapRooT_RCA

Generic Cause Analysis of the Navy’s Ship Collision/Grounding Problems

September 26th, 2017 by

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First, let me state that the reason I seem to be carried away by the failures of the Navy to implement good root cause analysis is that I spent seven years in the Navy and have compassion for the officers and sailors that are being asked to do so much. Our sailors and officers at sea are being asked to do more than we should ask them to do. The recent fatalities are proof of this and are completely avoidable. The Navy’s response so far has been inadequate at best.

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What should the Navy being doing? A thorough, advanced root cause analysis and generic cause analysis of the collisions and grounding in the 7th Fleet. And if you know me, you know that I think they should be using TapRooT® to do this.

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In TapRooT®, once you complete the analysis of the specific causes of a particular accident/incident, the next step is to identify the Generic Causes of the problems that caused that particular incident. Generic Causes are:

Generic Cause

The systemic cause that allows a root cause to exist.
Fixing the Generic Cause eliminates whole classes of specific root causes.

The normal process for finding generic causes is to look at each specific root cause that you have identified using the Root Cause Tree® and see if there is a generic causes using a three step process. The three steps are:

  1. Review the “Ideas for Generic Problems” section of the Corrective Action Helper® Guide for the root causes you have identified.
  2. Ask: “Does the same problem exist in more places?
  3. Ask: “What in the system is causing this Generic Cause to exist?”

It is helpful to have a database of thoroughly investigated previous problems when answering these question.

TapRooT® Users know about the Root Cause Tree® and the Corrective Action Helper® Guide and how to use them to perform advanced root cause analysis and develop effective corrective actions. If you haven’t been trained to use the TapRooT® System, I would recommend attending the 5-Day Advanced TapRooT® Root Cause Analysis Team Leader Training or reading the TapRooT® Essentials & Major Investigations Books.

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Unfortunately, we don’t have all the data from the recent and perhaps still incomplete Navy investigations to perform a TapRooT® Root Cause Analysis. What do we have? The press releases and news coverage of the accidents. From that information we can get a hint at the generic causes for these accidents.

Before I list the generic causes we are guessing at and discuss potential fixes, here is a disclaimer. BEFORE I would guarantee that these generic causes are accurate and that these corrective actions would be effective, I would need to perform an in-depth investigation and root cause analysis of the recent accidents and then determine the generic causes. Since that is not possible (the Navy is not a TapRooT® User), the following is just a guess based on my experience…

GENERIC CAUSES

1. INADEQUATE NUMBER OF SHIPS FOR THE USA FOREIGN POLICY COMMITMENTS

2. INADEQUATE STAFFING OF THE SHIPS WE HAVE

3. INADEQUATE TRAINING OF THE CREWS OF THE SHIPS WE HAVE

4. INADEQUATE WATCH SCHEDULES AND PRIORITIZATION OF TASKS FOR UNDERWAY REQUIREMENTS

5. INAEQUATE CREW TEAMWORK AND CREW TEAMWORK TRAINING

Some of these problems should be fairly easy to fix in six months to two years. Others will be difficult to fix and may take a decade if there is the will to invest in a capable fleet. All of the problems must be fixed to significantly reduce the risk of these types of accidents in the future. Without fixes, the blood of sailors killed in future collisions will be on the hands of current naval leadership.

POTENTIAL FIXES

5. INAEQUATE CREW TEAMWORK AND CREW TEAMWORK TRAINING

  • Establish a crew teamwork training class oriented toward surface ship bridge watch operations that can be accomplished while ships are in port.
  • Conduct the training for all ships on a prioritized basis.
  • Integrate the training into junior officer training courses and department head and perspective XO and CO training.
  • Conduct underway audits to verify the effectiveness of the training, perhaps during shipboard refresher training and/or by type command staffs.

4. INADEQUATE WATCH SCHEDULES AND PRIORITIZATION OF TASKS FOR UNDERWAY REQUIREMENTS

  • Develop a standard watch rotation schedule to minimize fatigue.
  • Review underway requirements and prioritize to allow for adequate rest.
  • Allow daytime sleeping to reduce fatigue.
  • Minimize noise during daytime sleeping hours to allow for rest.
  • Review underway drills and non-essential training that adds to fatigue. Schedule drills and training to allow for daytime sleeping hours.
  • Train junior officers, senior non-commissions officers, department heads, XOs, and COs in fatigue minimization strategies.
  • Implement a fatigue testing strategy for use to evaluate crew fatigue and numerically score fatigue to provide guidance for CO’s when fatigue is becoming excessive.

3. INADEQUATE TRAINING OF THE CREWS OF THE SHIPS WE HAVE

This corrective action is difficult because a through training requirement analysis must be conducted prior to deciding on the specifics of the corrective actions listed here. However, we will once again guess at some of the requirements that need to be implemented that are not listed above.

a. SEAMANSHIP/SHIP DRIVING/STATION KEEPING

Driving a ship is a difficult challenge. Much harder than driving a car. In my controls and human factors class I learned that it was a 2nd or 3rd order control problem and these types of problems are very difficult for humans to solve. Thus ship drivers need lots of training and experience to be good. It seems the current training given and experience achieved are insufficient. Thus these ideas should be considered:

  • A seamanship training program be developed based on best human factors and training practices including performing a ship driving task analysis, using simulation training, models in an indoor ship basin, and developing shipboard games that can be played ashore or at sea to reinforce the ship handling lessons. These best practices and training tools can be built into the training programs suggested below.
  • Develop ship handing course for junior officers to complete before they arrive at their first ship to learn and practice common ship handling activities like man overboard, coming alongside (replenishment at sea), station keeping, maneuvering in restricted waters, contact tracking and avoidance in restricted waters.
  • Develop an advanced ship handing corse for department heads that refreshes/tests their ship handling skills and teaches them how to coach junior officers to develop their ship handling skills. This course should include simulator training and at sea ship handling practice including docking scenarios, anchoring, restricted waters, and collision avoidance.
  • Develop an advanced ship handling course for COs/XOs to refresh/test their ship handling skills and check their ability to coach junior officers ship handling skills. This course should include simulator training and at sea ship handling practice including docking scenarios, anchoring, restricted waters, and collision avoidance. The course should also include training on when the CO should be on the bridge and their duties when overseeing bridge operations in restricted waters including when to take control if the ship is in extremis (and practice of this skill).
  • Develop a simulator test for junior officers, department heads, XOs, and COs to test their ship handing and supervisory skills to be passed before reporting to a ship.
  • Develop bridge team training to be carried out onboard each ship to reinforce crew teamwork training.

b. NAVIGATION

  • Perform a task analysis of required navigation shipboard duties including new technology duties and duties if technology fails (without shipboard computerized aids).
  • Develop a navigation training program based on the task analysis for junior officers, department heads, XOs, and COs. This program should completed prior to shipboard tours and should include refresher training to be accomplished periodically while at sea.

c. ROOT CAUSE ANALYSIS

  • Develop a department head leadership program to teach advanced root cause analysis for shipboard incidents.
  • Develop a junior officer root cause analysis course for simple (lower risk) problem analysis.
  • Develop a senior officer root cause analysis training program for XOs, COs, and line admiralty to teach advanced root cause analysis and review requirements when approving root cause analyses performed under their command. (Yes – the Navy does NOT know how to do this based on the current status of repeat incidents.)

2. INADEQUATE STAFFING OF THE SHIPS WE HAVE

  • Develop a senior officer (Captain and above) training program to teach when a CO or line responsible admiral should “push back” when given too demanding an operational schedule. This ability to say “no” should be based on testable, numerically measurable statistics. For example, shipboard fatigue testing, number of days at sea under certain levels of high operating tempo, number of days at sea without a port call, staffing levels in key jobs, …
  • Review undermanning and conduct a root cause analysis of the current problems being had at sea and develop an effective program to support at sea commands with trained personnel.

1. INADEQUATE NUMBER OF SHIPS FOR THE USA FOREIGN POLICY COMMITMENTS

  • Develop a numerically valid and researched guidance for the number of ships required to support deployed forces in the current operating tempo.
  • Use the guidance developed above to demonstrate to the President and Congress the need for additional warships.
  • Evaluate the current mothball fleet and decide how many ships can be rapidly returned to service to support the current operating tempo.
  • Review the mothballed nuclear cruiser and carrier fleet to see if ships can be refueled, updated, and returned to service to support current operating tempo and create a better nuclear surface fleet carrier path.
  • Establish a new ship building program to support a modern 400 ship Navy by 2030.
  • Establish a recruiting and retention program to ensure adequate staff for the increased surface fleet.

Note that these are just ideas based on a Generic Cause Analysis of press releases and news reports. Just a single afternoon was spent by one individual developing this outline. Because of the magnitude of this problem and the lives at stake, I would recommend a real TapRooT® Root Cause Analysis of at least the last four major accidents and a Generic Cause Analysis of those incidents before corrective actions are initiated.

Of course, the Navy is already initiating corrective actions that seem to put the burden of improvement on the Commanding Officers who don’t have additional resources to solve these problems. Perhaps the Navy can realize that inadequate root cause analysis can be determined by the observation of repeat accidents and learn to adopt and apply advanced root cause analysis and support it from the CNO to the Chiefs and Junior Officers throughout the fleet. Then senior Navy officials can stand up and request from Congress and the President the resources needed to keep our young men and women safe at sea.

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Is punishment the best way to improve performance in the Navy?

September 20th, 2017 by

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In my decades of root cause analysis, less than 2% of incidents are caused by some sort of willful action that does not have a system cause. However, in many incident responses, companies discipline people for mistakes that were caused by system problem. This unwarranted punishment leads to:

  • Covering up problems.
  • Lying about what people did.
  • Morale issues when people are punished for things that were not their fault.
  • Mystery incidents that no one seems to know anything about (no one will talk).
  • Poor performance because the root causes of the problems are not being addressed.

Thus, I was disappointed when I saw the US Navy resort to discipline before the root cause analysis was completed after the collision of the USS Fitzgerald. Then again more discipline was used (this time against an Admiral) after the collision of the USS John S. McCain.

I wrote several articles about the collisions:

What is the Root Cause of the USS Fitzgerald Collision?

US Navy 7th Fleet Announces Blame for Crash of the USS Fitzgerald

USS Fitzgerald & USS John S McCain Collisions: Response to Feedback from a Reader

Several senior naval officers and others that discipline was needed for Navy personnel when a mission fails or a ship collides with another.

This brought to mind two sayings that I learned in the Navy. The first is:

The beatings will continue until morale improves.

The second is:

Why be fair when you can be arbitrary.

Do people in the Navy really respond to random discipline? The kind of discipline that’s been proven not to work in the civilian world?

I spent 7 years in the US Navy and have had close contacts with many people in the Navy since I left to start my civilian career. What I can tell you is this:

  1. Being at sea is different than working in a civilian job
  2. The Navy generally has a stricter set of operating rules than a civilian workforce does.
  3. There is a wider range of disciplinary actions that are available in the Navy than in the civilian word. (Although flogging and keel-hauling have been eliminated.)
  4. You can’t quit in the Navy if you have a bad boss.
  5. It’s difficult to fire someone that works for you if they are incompetent (you are stuck with those who you are assigned to lead).
  6. People ARE NOT different. They don’t become some sort of robot just because they joined the Navy.

Why did I include point #6 above? Because I’m often told that discipline is needed in the Navy to improve performance (One Admiral told me that it “sharpens the Commanding Officers game”).

It seems that some believe that senior naval officers (people commanding Navy ships – the Commanding Officers or COs) would try less hard, be less alert, and have worse performance if they didn’t have the threat of being relieved of command if they run into another ship or run aground.

Yes – the CO is ultimately responsible. Therefore, how could it NOT be the CO’s fault? They have ultimate authority on their ship … don’t they?

Let’s look at a an example. What if:

  • A ship was assigned a rigorous operational schedule of demanding technical missions.
  • The ship had several key pieces of equipment that that had been reported as broken (because of lack of time, parts, and money to perform maintenance).
  • The ship had many junior, barely qualified personnel serving in key positions because of the Navy’s planned rotation of officers and enlisted personnel and planned reduction of ashore training before new personnel arrived for their tour of duty.
  • The ship was undermanned because new ships were designed with new, smaller, crews but still had the same work to be performed as on older ships with 20-30% more people. This saved the Navy budget money – especially in the time of sequester.
  • The ship had several key personnel left ashore – with no replacement – because they were pregnant.
  • The CO was new to the ship and had little experience with this type of ship because he was assigned wartime duties ashore in Iraq during the Gulf Wars and missed an Executive Officer and a Department Head tours that would have provided more applicable experience and knowledge for this assignment.
  • People were fatigued after several tough evolutions but still had to drive the ship through a narrow, busy straight to get to their next assigned mission.

Is any of this under the CO’s control? Don’t these circumstances contribute to a mission failure if one occurs (like a collision). Would discipline make any of these factors change?

Does telling the CO that you are going to punish him (or her) if he or his crew makes a mistake make ANY difference?

Please leave me your comments. I’d be interested in what you have to say.

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Root Cause Analysis for the FDA

September 13th, 2017 by

RootCauseAnalysis

What does the FDA want when you perform a root cause analysis?

The answer is quite simple. They want you to find the real, fixable root causes of the problem and then fix them so they don’t happen again.

Even better, they would like you to audit/access your own processes and find and fix problems before they cause incidents.

And even better yet, they would like to arrive to perform a FDA 483 inspection and find no issues. Nothing. You have found and fixed any problems before they arrive because that’s the way you run your facility.

How can you be that good? You apply root cause analysis PROACTIVELY.

You don’t want to have to explain and fix problems found in a FDA 483 inspection or, worse yet, get a warning letter. You want to have manufacturing excellence.

TapRooT® Root Cause Analysis can help you reactively find and fix the real root causes of problems or proactively improve performance to avoid having quality issues. Want to find out how? Attend one of our guaranteed root cause analysis courses. See:

http://www.taproot.com/courses

I’d suggest one of our public 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Courses to get started. Then have a course at your site to get everyone involved in improving performance.

Want more information before you sign up for a course? Contact us by CLICKING HERE.

Why is getting the best root cause analysis training possible a great investment?

August 23rd, 2017 by

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Why do you train employees to investigate accidents, incidents, quality problems, equipment failures, and process upsets? Because those events:

  • Cost Lives
  • Cause Injuries
  • Ruin the Reputation of Your Product and Company
  • Cause Regulatory Issues (and Big Fines)
  • Cause Expensive Downtime
  • Cause Missed Schedules and Delayed Shipments

You want to learn from past problems to prevent future issues. Its even better if you can learn from small problems to prevent big accidents.

Therefore, you invest in your employees education because you expect a return on your investment. That return is:

  • No Fatalities
  • Reduced Injuries (Better LTI Stats)
  • A Reputation for Excellent Product Quality
  • Good Relations with Your Regulators and Community
  • Excellent Equipment Reliability and Reduced Corrective Maintenance Costs
  • Work Completed on Schedule
  • Shipments Go Out On Time and On Budget

When you think about your investment in root cause analysis training, think about the results you want. Review the diagram below (you’ve probably seen something like it before). Many managers want something for nothing. They want fast, free, and great root cause analysis training. But what does the diagram say? Forget about it! You can’t even have fast-great-cheap (impossible utopia). They usually end up with something dipped in ugly sauce and created with haste and carelessness! (Does 5-Why training ring a bell?)

NewImage(from Len Wilson’s blog)

What should you choose? TapRooT® Training. What does it do for you? Gives you guaranteed return on your investment.

What? A guarantee? That’s right. Here is our TRAINING GUARANTEE:

Attend a course, go back to work, and use what you have learned to analyze accidents, incidents, near-misses, equipment failures, operating issues, or quality problems. If you don’t find root causes that you previously would have overlooked and if you and your management don’t agree that the corrective actions that you recommend are much more effective, just return your course materials/software and we will refund the entire course fee.

How can we make such an iron-clad guarantee? Because we have spent almost 30 years developing the world’s best root cause analysis system that has been tested and reviewed by experts and used by industry leaders. Over 10,000 people each year are trained to use TapRooT® to find and fix the root causes of accidents, quality problems, and other issues. Because of this extensive worldwide user base, we know that TapRooT® will help you achieve operational excellence. Thus, we know your investment will be worthwhile.

Plus, we think you will be happy with the investment you need to make when you see the results that you will get. What kind of results? That depends on the risk you have to mitigate and the way you apply what you learn, but CLICK HERE to see success stories submitted by TapRooT® Users.

Don’t think that the return on investment has to be a long term waiting game (although long term investments are sometimes worthwhile). Read this story of a FAST ROI example:

One of the students in a 5-Day TapRooT® Advanced Root Cause Team Leader Course came up to me on day 3 of the course and told me that the course had already paid for itself many times over.

I asked him what he meant. He said while we were teaching that morning, he identified a problem in some engineering work they were doing, and the savings he had avoided, (he had immediately called back to the office), totaled over $1 million dollars.

That’s a great return on investment. A $2500 course and a $1,000,000 payback. That’s about a 40000% instant ROI.

How much value can you achieve from your investment in great root cause analysis? Consider these issues:

  • How much is human error costing your company?
  • If the EPA fines you $100,000 per day for an environmental permit violation, how much could it cost?
  • What is your reputation for product quality worth?
  • How much is just one day of downtime worth to your factory?
  • How much would a major accident cost?

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I’m not asking you to take my word for how much great root cause analysis training (TapRooT® Training) will help your company. I’m just asking you to give it a try to see how much it can help your company.

Just send one person to one of our 2-Day or 5-Day TapRooT® Courses. Then see how they can help solve problems using the TapRooT® Techniques. I know that you will be pleased and I’ll feel good about the lives you will save, the improvements in quality that you will make, and the improved bottom line that your company will achieve when you get more people trained.

See the list of upcoming public TapRooT® Training being held around the world:

http://www.taproot.com/store/Courses/

 Or contact us for a quote for a course at your site:

http://www.taproot.com/contact-us

US Navy 7th Fleet Announces Blame for Crash of the USS Fitzgerald

August 18th, 2017 by

USS Fitzgerald

The Navy has taken the first action to avoid future collisions at sea after the crash of the USS Fitzgerald. The only question that remains is:

Why did it take Rear Admiral Brian Fort two months to determine who the Navy would punish?

After all, they knew who the CO, XO, and Command Master Chief were and they could just check the watch bill to see who was on the bridge and in CIC. That shouldn’t take 60 days. Maybe it took them that long to get the press release approved.

The Navy’s Top Secret root cause analysis system is:

Round up the usual guilty parties!

Here is what the Navy press release said:

“The commanding officer, executive officer and command master chief of the guided-missile destroyer USS Fitzgerald (DDG 62) were relieved of their duties by Vice Adm. Joseph Aucoin, Commander, 7th Fleet Aug, 18. 

Additionally, a number of officer and enlisted watch standers were held accountable. 

The determinations were made following a thorough review of the facts and circumstances leading up to the June 17 collision between Fitzgerald and the merchant vessel ACX Crystal.”  

Yet here is a part of the announcement from the Navy’s PR Officer:

“It is premature to speculate on causation or any other issues,” she said. “Once we have a detailed understanding of the facts and circumstances, we will share those findings with the Fitzgerald families, our Congressional oversight committees and the general public.”

The emphasis above was added by me.

It is premature to speculate on causes BUT we already know who to blame because we did a “thorough review of the facts.”

Now that all the BAD sailors have been disciplined, we can rest easy knowing that the Navy has solved the problems with seamanship by replacing these bad officers and crew members. There certainly aren’t any system causes that point to Navy brass, fleet-wide training and competency, or fatigue.

As I said in my previous article about this collision:

“Of course, with a TapRooT® investigation, we would start with a detailed SnapCharT® of what happened BEFORE we would collect facts about why the Causal Factors happened. Unfortunately, the US Navy doesn’t do TapRooT® investigations. Let’s hope this investigation gets beyond blame to find the real root causes of this fatal collision at sea.”

With blame and punishment as the first corrective action, I don’t hold out much hope for real improvement (even though the Navy has a separate safety investigation). Perhaps that’s why I can’t help writing a scathing, sarcastic article because the Navy has always relied on blame after collisions at sea (rather than real root cause analysis). Our young men and women serving aboard Navy ships deserve better.

I won’t hold my breath waiting for a call from the Navy asking for help finding the real root causes of this tragic accident and developing effective corrective actions that would improve performance at sea. This is just another accident – much like the previous collisions at sea that the Navy has failed to prevent. Obviously, previous corrective actions weren’t effective. Or … maybe these BAD officers were very creative? They found a completely new way to crash their ship!

My guess is that Navy ships are being “ridden hard and put up wet” (horse riding terminology).

My prediction:

  1. The Navy will hold a safety stand down to reemphasize proper seamanship. 
  2. There will be future collisions with more guilty crews that get the usual Navy discipline.

That’s the way the Navy has always done it since the days of “wooden ships and iron men.” The only change … they don’t hang sailors from the yard arm or keel haul them in the modern Navy. That’s progress!

Bless all the sailors serving at sea in these difficult times. We haven’t done enough to support you and give you the leadership you deserve. Senior naval leadership should hang their heads in shame.

ACE – How do you find the root causes?

August 16th, 2017 by

Ace clipart four aces playing cards 0071 1002 1001 1624 SMU

First, for those not in the nuclear industry …

What is an ACE?

An ACE is an Apparent Cause Evaluation.

In the nuclear industry management promotes official reporting of ALL problems. The result? Many problem reports don’t deserve a full root cause analysis (like those performed for major investigation).

So how do nuclear industry professionals perform an ACE?

There is no standard method. But many facilities use the following “system” for the evaluation:

  1. Don’t waste a lot of time performing the evaluation.
  2. Make your best guess as to the cause.
  3. Develop a simple corrective action.
  4. Submit the evaluation for approval and add the corrective actions into the tracking and prioritization system.

That’s it.

How does that work? Not so good. Read about my opinion of the results here:

The Curse of Apparent Cause Analysis

That article is pretty old (2006), but my opinion hasn’t changed much.

So what do I recommend for simple incidents that don’t get a full investigation (a full investigation is described in Using TapRooT® Root Cause Analysis for Major Investigations)? I describe the process fully in:

Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents

Here’s a flow chart of the process…

SimpleProcess

For all investigations you need to find out what REALLY happened. Then you make an important decision …

Is there anything worth learning here?

Many investigations will stop here. There is nothing worth spending more time investigating OR fixing.

The example in the book is someone falling while walking on a sidewalk.

If you decide there IS more to learn, then a simplified TapRooT® Process is used.

This process includes identifying Causal Factors, finding their root causes using the Root Cause Tree® Diagram, and developing fixes using the Corrective Action Helper® Guide.

That’s it. No Generic Cause Analysis and no fixing Generic Causes.

Want to learn more? Read the book. Get your copy here:

http://www.taproot.com/store/TapRooT-and-reg-investigation-Essentials-Book-set.html

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