Category: Root Cause Analysis Tips

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.

Interviewing & Evidence Collection Tip: How to Handle an Inconsistent Statement

October 26th, 2017 by

 

 

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Not every inconsistent statement is meant to deceive.

 

A new investigator may believe that if an interviewee is telling the truth, he will be consistent in his recollection of an event every single time. However, not every inconsistent statement made by an interviewee is made to intentionally deceive.

In fact, most interviewees want to be helpful. Further, an inconsistent statement may be as accurate or even more accurate than consistent claims. That is, an account repeated three times with perfect consistency may be more of a red flag to dig deeper.

The two most important things to think about when evaluating inconsistencies are the passage of time between the incident and its recollection, and the significance of the event to the interviewee. Passage of time makes memory a bit foggy, and items stored in memory that become foggy the quickest are things that we don’t deem significant, like what we ate for lunch last Wednesday. That being said, we still have to be on the lookout for possible fallacies and know how to test them.

There are four ways to decrease the possibility of innocent inconsistent statements during the interviewing process.

  1. Encourage the interviewee to report events that come to mind that are not related or are trivial. In this way, you discourage an interviewee trying to please you by forcing the pieces to fit. They do not know about all the evidence that has been collected, and may believe that something is not related when it truly is.
  2. Tell the interviewee, explicitly, not to try to make-up anything he or she is unsure of simply to prove an answer. If they don’t know, simply request they say, “I don’t know.” This will help them relax.
  3. Do not give feedback after any statement like “good” or “right.” This will only encourage the interviewee to give more statements that you think are “good” or “right”– and may even influence them to believe that some things occurred that really didn’t.
  4. Ask the interviewee to tell the story of what happened from finish to start instead of start to finish. If the interviewee is intentionally trying to cover something up, he or she will have a hard time remembering the same order to the story he or she recited the first time because the interviewee will have a greater cognitive load to bear telling the story in reverse order.

We have plans to go over many more details on how to conduct a good interview at the 2018 Global TapRooT® Summit. Join us for TapRooT® Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills February 26 and 27. Learn more.

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.

Root Cause Tip Warning: Do not define the impact level of your incident too low or too high

October 19th, 2017 by

 

When defining the Incident during a TapRooT® Root Cause Analysis and its impact to the business (the scope of your investigation), I often hear this statement…

“If we focus on the delay of correcting the problem, then less importance will be placed on what caused the problem.”

Take the scenario of a fire pump failing to turn on during a fire response test. The team originally wanted to focus on the pump failure only. Not a bad idea however, the pump could not be repaired for 2 weeks because of a spare part shortage. I pushed the team to raise the scope and impact of the investigation to Automatic Fire Suppression System out of service for 14 days.

Now this elevation of the incident does not lessen the focus on the pump failure, it does the opposite. A system down for 2 weeks elevates the focus on the pump failure because of impact and also allows the team to analyze why we did not have access to spare pump in a timely manner.

A caution also must be mentioned in that elevating the impact of an incident too high can cause a regulating agency to get involved or/and additional resources to be spent when not required.

Which problem is worse? Elevating a problem too high or not high enough? Your thoughts?

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.

Interviewing & Evidence Collection Tip: Get More Out of Interviews

October 5th, 2017 by

Where can you find a good portion of information to complete your SnapCharT®? Interviews! And how do we obtain interviews? People!

Why do we often forget that we are collecting information from human beings? Remember that an accident investigation may be a stressful event for everyone involved. There may be serious injuries and worries about the repercussions of participating in interviews or worries about whatever discipline the employer may impose in a blame culture.

Throughout the process, treat everyone with sensitivity:

  • Be ready for the interview.
  • Greet the interviewee by name, a firm handshake and a smile.
  • Break the ice by initiating a brief conversation not related to the incident. Put the interviewee at ease by listening to their contributions to the conversation without interruption.
  • Explain the interview process so they know what to expect.
  • Make it a practice to review the notes with the interviewee at the end of the interview. Let them know you will be doing that after explaining the process. They will feel more at ease if they have the opportunity to make any clarifications necessary.

Consideration for people’s fears goes a long way toward earning buy-in and confidence in the process.

What other things do you do to help an interviewee feel comfortable with the interview process? Share your ideas in the comments section below.

Root Cause Tip: Courage

October 4th, 2017 by

Courage is not limited to the battlefield or the Indianapolis 500 or bravely catching a thief in your house.  The real tests of courage are much quieter.  They are inner tests, like remaining faithful when nobody’s looking, like enduring pain when the room is empty, like standing alone when you’re misunderstood. ~ Charles Swindoll

Investigating accidents, incidents, sentinel events, equipment failures, and quality issues requires courage.  Courage to challenge the way work is performed.  Courage to ask questions that people hope won’t be asked.  Courage to point out ways that management can improve the way the facility is managed.

Remember, when you think you face the challenge of confronting people and influencing them to change … courageously look for a different path.

Instead of forcing your views, find a way to make yourself an ally of those you think must change.  Your objective is to create an environment where you have an opportunity to share your vision and create enthusiasm for it.  As an ally, you learn how they view the problem in greater detail.  You may even discover some of your assumptions were wrong.  As an ally, they are more open to receive your ideas.  When you are work as a team – rather than adversaries – the chances of success are much higher.

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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Kicking over rocks

September 20th, 2017 by

Happy Wednesday, and welcome to this week’s root cause analysis tips.

Today I would like to address an interesting question; what do I do with information about problems I encounter during my investigation that turn out to not have anything to do with the incident I am investigating?

When we are in the beginning stages of an investigation, we are gathering as much information as possible and compiling the information on our SnapCharT®. We then define causal factors, perform root cause analysis, and apply corrective actions. In the process of gathering information, we may “kick over some rocks” and you know what happens next……things start to pop out.

For example, you might be doing an investigation and during the document review, you find that training records are out of compliance. As you continue through the investigation, you might determine that training was not an issue for this incident. But should you ignore the non-compliance? You can’t.

That example is a compliance problem, so it is a no brainer, it has to be addressed. But what about process improvements? You might find some real problems with one of your processes but they may have nothing to do with the incident you are investigating. In my previous life this was one of my strengths, but it was also a curse at times, because it would create a lot of extra work! I would quickly solve the actual problems that caused the incident but end up with a two-year project over something that popped out from under the rocks. As professionals, you know what is important and you know what your resources are, so prioritize and solve some problems; I think you will find it is worth it.

So as you uncover things like this, make a list of them and address them after you have finished your investigation. Be careful not to get side-tracked, make sure you take care of the matters at hand first. After you have issued your investigation report you can work on the other things.

One best practice that one of our clients shared with me is that rather than making a list like I suggested, when they start pruning their SnapCharT®, they move the other issues they want to address to a separate page of the chart so they have it all in one place. I like that.

If you have been to one of our courses, you know that when we talk about proactive use of TapRooT®, we teach the concept of “significant issues,” the proactive equivalent of casual factors (in a reactive application). You can do root cause analysis of these significant issues you discover during an investigation just as you would those you find during an audit. If you want to look at an entire process, just map the process out and spot potential failure points, and perform root cause analysis on them.

Problem solving is a lot more fun than investigating incidents. And you never know, the problem you solve today might be the investigation you don’t have to do tommorrow!

Root Cause Tip: Are you stopping short of exploring Human Engineering on the TapRooT® Root Cause Tree®?

September 14th, 2017 by

 

When analyzing a Causal Factor for Human Performance Difficulty during a root cause analysis investigation, a few questions under the Individual Performance section of the TapRooT® Root Cause Tree® will guide you to the basic cause category of Human Engineering. Hint: It would be great to have your Root Cause Tree® and Root Cause Tree® Dictionary handy for this discussion but it is not mandatory for learning to occur from this article.

Question 1: This question focuses on factors that can reduce human reliability and cause human errors. (Fitness of Worker performing a task)

Question 4: This question focuses on the human-machine interface that was needed to recognize conditions or problems and understand what was occurring. (Machine readouts and display feedback provided while performing a task)

Question 5: This question covers actual task performance. (Interaction while operating the equipment while performing a task)

Question 7: This question focuses on environmental factors that can degrade human performance. (Environment factors where the task is being performed)

Question 8: This question focuses on the ergonomics of the task performance. (Acute or repetitive issues and the physical impact on the person performing a task)

By now you should notice two key factors that must be identified before you can go any further in the root cause analysis of a particular Causal Factor for Human Engineering:

1. Who is the person that needed to perform the task successfully?

2. What is the task that needed to be performed successfully?

No shortcuts allowed in our TapRooT® process for these two factors. Doing so will prematurely cancel out your opportunity to explore Human Engineering in more investigative detail.

A third factor not listed yet is that you must Go Out And Look (GOAL) at where the task is being performed for questions 4, 5, 7 and 8. You cannot and should not answer the additional questions needed to evaluate the task from your desk. If you cannot get to the site and must ask the questions remotely, a person must be onsite to be your ears and eyes to GOAL.

A task can defined as an activity or piece of work which a person(s) must perform to accomplish with a successful end result. It can be a one action task or a sequence of actions to accomplish a system response. Examples….

• Press brake pedal with right foot to slow down car that you are driving
• Type words that create a sentence for others to read and comprehend
• Calculate launch equations that then get input into a computer that then guides a space capsule launch


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What would it take for a person to press a pedal with their right foot to slow down a vehicle?

• A pedal that can be reached and depressed
• A pedal that works as designed for the task
• Feedback from the car and environment to indicate that the car is slowing down at the right rate
• A person that can react in time with the right knowledge and ability to perform the slowing down task

How hard would it be to answer these questions from your desk with a reasonable amount of accuracy? Difficult at best, so don’t stop yourself from exploring Human Engineering because you did not identify the task, the equipment and the person.

Learn more about Human Engineering and TapRooT® tools like the TapRooT® Root Cause Tree in one of our upcoming 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Trainings:

October 2: Knoxville, Tennessee

October 16: Orlando, Florida

October 23: Bogota, Colombia (Spanish)

October 30: Reykjavik, Iceland

November 13: Brisbane, Australia

November 13: New Orleans

November 27: Johannesburg, South Africa

November 27: Monterrey, Mexico

November 27: Perth, Australia

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.

The world’s most modern Navy struggles with outdated culture

September 6th, 2017 by

To students of safety and accident prevention, the recent collisions involving the guided missile destroyers USS Fitzgerald (DDG 62) and USS John S. McCain (DDG 56) seem strange. How can this happen with top shelf modern warships, equipped with state-of-the-art electronics, radar and GPS? Hint: look for human performance issues, and a culture of blame and punishment.

These are tragic accidents, with unnecessary loss of lives. The Navy’s immediate response was a 24-hour “safety stand down,” and a 60-day review of surface fleet operations, training, and certification. Perhaps more significantly, the Seventh Fleet commander Vice Admiral Aucoin was fired, due to a “loss of confidence in his ability to command.”

And this is where the problems start. To an outside observer, the Navy culture of “firing those responsible” seems very old fashioned. Not only do we waste money on repairing ship damage that should never have happened, we also voluntarily get rid of a large investment in recruiting and training with each officer let go.

A better answer is to analyze what happened in each case, find the root causes and put in place corrective actions to prevent the same accidents from happening again. The Navy investigation results are classified, but let me offer up two possible causes:

1. Guided missile destroyers are smaller, leaner and meaner than the conventional destroyers they replaced. They sail with a smaller crew and fewer officers. However, there is still the same amount of horizon to scan, so to say, so officers will have larger spans of responsibility and fewer opportunities to rest. Fatigue is a powerful influence on human performance.

2. The world is a dangerous place, and getting worse. A shrinking Navy is deployed on the same number of missions around the world, not allowing enough time in between for maintenance of ships and systems. Training and development of crews also suffers.

Our long experience in root cause analysis tells us that no matter how sophisticated systems or equipment are, they need maintenance to work properly. There is also always human factors involved. Human performance is fickle, and influenced by many factors such as fatigue, alertness, training, or layout of control panels. It is better to do a thorough RCA to identify causal factors and fix them, than to fire people up and down the chain of command and still have the same issues again later.

#TapRooT_RCA

Corrective Action Advice

September 6th, 2017 by

If you use TapRooT® to find the root causes of incidents, quality issues, hospital sentinel events, equipment failures, production issues, and cost overruns, you are way ahead of your competition that is just asking “Why” five times. But what should you do to stop repeat incidents when you fix the causes of your problems?

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1. Remove the Hazard and/or the Target.

If you have been to TapRooT® Training you know what a Hazard and a Target are. Did you realize that the most effective fix is to get rid of them (if you can).

If you can get rid of them, you still may want to fix the causes of the root causes you identify. However, is there is no Hazard, you can be pretty sure you won’t have that accident happen again.

2. Install a more reliable Safeguard.

Once again, if you have been to TapRooT® Training, you know what a Safeguard is.

To have your previous incident, all the Safeguards for that incident had to fail. These failed Safeguards were your Causal Factors.

Strengthening your failed Safeguards is what root cause analysis is all about. But how much stronger can you make a weak Safeguard?

Perhaps a better idea is to implement a strong Safeguard?

An example would be to replace several weak Human Action Safeguards with a strong Engineered Safeguard.

CAHelperGuide

3. Fix the root causes of the failed Safeguards.

Use your Corrective Action Helper® Guide/Software Module to develop effective fixes for the root causes of the failed Safeguards that you identified. The Corrective Action Helper® Guide is a great way to get new ideas to fix problems that you previously just couldn’t seem to fix.

4. Get your fixes implemented.

It is no use to develop fixes and put them in a database (the backlog) and never get them implemented. make sure that corrective actions get done!

TapRooT® featured on Worldwide Business with kathy ireland®

September 5th, 2017 by

Mark & Kathy discussing root cause analysis and human performance.

Watch the recorded television broadcast below.

Should you use TapRooT® to find the root causes of “simple” problems?

August 30th, 2017 by

Everybody knows that TapRooT® Root Cause Analysis is a great tool for a team to use when investigating a major accident. But can you (and should you) use the same techniques for a seemingly simple incident?

Lots of people have asked us this question. Instead of just saying “Yes!” (as we did for many years), we have gone a step further. We have created guidance for someone using TapRooT® when investigating low-to-moderate risk incidents.

Can you get this guidance? YES! Where? In our new book:

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

TapRooT Essentials Book

For “simple” incidents, we just apply the essential TapRooT® Techniques. This makes the investigation as easy as possible while still getting great results. Also, because you perform a good investigation, you can add your results to a database to find trends and then address the Generic Causes as you collect sufficient data.

Also, this “simple” process is what we teach in the 2-Day TapRooT® Training. See our upcoming public 2-Day TapRooT® Courses here:

http://www.taproot.com/store/2-Day-Courses/

Now … WHY should you use TapRooT® to analyze “simple” problems rather than something “simple” like 5-Whys?

Because:

  1. Even though the incident may seem simple, you want to find and fix the real root causes and not just focus on a single causal factor and end up with “human error” as a root cause (as happens many times when using 5-Whys).
  2. When you use TapRooT® for simple incidents, you get more practice using TapRooT® and your investigators will be ready for a bigger incident (if you have one).
  3. You want to solve small problems to avoid big problems. TapRooT® helps you find and fix the real root causes and will help you get the great results you need.
  4. The root causes you find can be trended and this allows analysis of performance to spot Generic Causes.
  5. Your management and investigators only learn one system, cutting training requirements.
  6. You save effort and avoid needless recommendations by applying the evaluation tool step built into the simple TapRooT® Process. This stops the investigation of problems that aren’t worth investigating.

That’s six good reasons to start using TapRooT® for your “simple” investigation. Get the book or attend the course and get started today!

Root Cause Tip: Equipment difficulty… did the equipment break or wear out?

August 28th, 2017 by

Teaching TapRooT® Root Cause Analysis and Equifactor® for the last 10 years, I often get this question…

“The tool/component broke while we were using it. Why can’t we just select Equipment Difficulty on the TapRooT® Root Cause Tree®?”

Simple, you have to pass the test below first

NOTE: If the failure was caused by:

  – improper operation;

  – improper maintenance;

  – installation errors;

  – failure to perform scheduled preventive maintenance;

  – programming errors;

  – use for a purpose far beyond the intention of the design; or

  – a design that causes a human performance difficulty

then the failure is NOT an Equipment Difficulty, but rather the failure is a Human Performance Difficulty

Trust me! If a tool, piece of equipment or product breaks, you know the manufacturer, vendor and supplier are going to push back to see if it was used properly and meets the warranty. Shouldn’t you ask first? We say yes!

During my 18 years in aviation in fuel systems troubleshooting and executive jet assembly, we used to have a phrase…

“Our mechanics or assemblers that grew up on the farm are our best and worst mechanics. They can get anything mechanical to work.”

Now there are signs that tools might not be the right ones for the job or that the job was not designed with good Human Engineering in mind. First test… look into the toolboxes in the field.

✔Are the tools modified
✔Are the tools old and worn
✔Are there tools from home

Okay, so tools are easier to see being misused, like a screw driver being used as a scraper or a pry bar, but what about equipment/components being used like a…

✔ Compressor
✔ Switch
✔ Valve
✔ Bottle

Now we must dig a little deeper in our TapRooT® Root Cause and Equifactor® Analysis. We start by mapping out our SnapCharT® (Sequence of Events with supporting Conditions) using system schematics to ensure we know what occurred with the equipment, people and system being operated. A knowledgeable system operator can elaborate on events and conditions such as:

✔ Energized open, mechanically closed
✔ Dynamic or static energy
✔ System work arounds and deficiencies

Why you may ask is this knowledge vital? If an operator knows how the light turns on when you flip a light switch on, then when system does fail, it is easier to start and understand the SnapCharT®.

To pass the first two tests while facilitating TapRooT® Root Cause Analysis, whether for a low to moderate level issue or a major incident, bring along that knowledgeable operator or engineer that can answer the following…

improper operation;
improper maintenance;
installation errors;
failure to perform scheduled preventive maintenance;
programming errors;
use for a purpose far beyond the intention of the design; or
a design that causes a human performance difficulty

Good luck and be safe! Please get rid of those unsafe tools and processes.

LEARN MORE in our 2-day TapRooT® Root Cause Analysis Training.

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?)

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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

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

Interviewing and Evidence Collection Tip: Why Sketch the Scene?

August 3rd, 2017 by

Sketch the scene after video and photography.

So, an incident occurred and you’re moving along in your evidence collection efforts.  You’ve recorded the scene with both video and photography. You’re feeling pretty good about your documentation.  Is there any reason to also sketch the scene?

Yes, there are – and here are two very good reasons:

1. Sketching the scene on paper is valuable because photographs and video can make objects appear closer together or farther apart than they really are.  If the evidence needs to have proportional measurements included in it, sketch it!

2. Sketches can be used in sensitive situations.  For example, if the recordings (photographs and videos) of an accident scene are disturbing to witnesses, you can use sketches of the scene when interviewing them.

To learn more about evidence collection, join me in Houston, Texas in November for a 3-day root cause analysis and evidence collection course, or just 1 day of evidence collection training.

How Much Do You Believe?

August 1st, 2017 by

I was talking to my kids about things they read (or YouTube videos) on the internet and asked them …

How much of what you see online do you believe?

I told them that less than half of what I see or read online is believable (maybe way less than half).

But the next question I asked was more difficult …

How do you know if something is believable? How would you prove it?

This made them think …

I said that I have a lifetime of experience that I can use to judge if something sounds believable or not. Of course, that isn’t proof … but it does make me suspicious when something sounds too good to be true.

They didn’t have much life experience and therefore find it harder to judge when things are too good to be true.

However, we all need to step back and think … How can I prove something?

What does that have to do about accident and incident investigations?

Do you have a built-in lie detector that helps you judge when someone is making up a story?

I think I’ve seen that experienced investigators develop a sense of when someone is making up a story.

We all need to think about how we collect and VERIFY facts. Do we just accept stories that we are told or can we verify them with physical evidence.

The 1-Day TapRooT® Effective Interviewing & Evidence Collection Course that will be held in Houston on November 8th will help you think about your interviews and evidence collection to make your SnapCharT® fact based. In addition to the 1-Day Interviewing Course you can also sign up for the 2-Day TapRooT® Root Cause Analysis Course being held in Houston on November 6-8 by CLICKING HERE.

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Barb Phillips will be the instructor for the Effective Interviewing & Evidence Collection Course. Don’t miss it!

Company Culture Root Cause Tip: Trust Me the Foreman Said…

July 28th, 2017 by

No matter what industry that you work in, if you or your peers can say, “it’s common for management to argue or ‘explain away’ my concerns when you say this is unsafe…”

STOP!

If you do not stop, you will get to explore a root cause from the TapRooT® Root Cause Tree. The root cause will be Employee Feedback Needs Improvement. Unfortunately, it will also be associated with a causal factor that caused an incident, failed to stop an incident or made an incident worse when it occurred. Don’t forget, You are just one Causal Factor from your next major Incident. Can you prevent it?

During the root cause analysis, not only will you be exploring the culture of the company that allowed this failure not to stop, but you also will get the opportunity to understand what was broke.

Please be aware, that in this article and the included article links, I have only touched just the tip of each subject and introduced a very tiny part of our root cause analysis process. It is hoped that you leave with something you can use today and pay it forward. But also help you realize that there are numerous issues that must be addressed following an incident or before one occurs. We help you get there.

If you don’t want to have to read between three or four articles to do to an investigation, come to one of our public TapRooT® Courses or contact us for an onsite course. Why? Simple, each course provides Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents, Course Workbook, the complete Root Cause Tree®, Root Cause Tree® Dictionary, and Corrective Action Helper®.

Interviewing and Evidence Collection: Prepare to Record the Scene

July 27th, 2017 by

In TapRooT®, we use a mnemonic to quickly remember what types of evidence we may want to collect after an incident occurs: 3 Ps & an R. This stands for:

People evidence
Paper evidence
Physical evidence and
Recording evidence.

Recordings may include any photographs or video you capture. It may also include archived recordings such as computer data or security video.

Today, I have some quick reminders about things to consider in preparation of recording the scene (video or photographs).

First, ensure the battery is fully charged. I know, this is elementary right? Well, it is until you don’t do it and the battery dies in the middle of recording.

Second, remember to turn on the time and date display functions.  Then, you will have an automatic record of when the video was recorded or the photographs were taken without writing it down anywhere.

Third, clear the area of people.  Why? You do not want to record any embarrassing or inaccurate statements on video,  and you don’t want to place people at the scene who were not there originally on video or in a photograph.

To learn more about evidence collection, join me in Houston, Texas in November for a 3-day root cause analysis and evidence collection course, or just 1 day of evidence collection training.

Is There Just One Root Cause for a Major Accident?

July 26th, 2017 by

NewImage

Some people might say that the Officer of The Deck on the USS Fitzgerald goofed up. He turned in front of a containership and caused an accident.

Wait a second. Major accidents are NEVER that simple. There are almost always multiple things that went wrong. Multiple “Causal Factors” that could be eliminated and … if they were … would have prevented the accident or significantly reduced the accident’s consequences.

The “One Root Cause” assumption gets many investigators in trouble when performing a root cause analysis. They think they can ask “why” five times and find THE ROOT CAUSE.

TapRooT® Investigators never make this “single root cause” mistake. They start by developing a complete sequence of events that led to the accident. They do this by drawing a SnapCharT® (either using yellow stickies or using the TapRooT® Software).

They then use one of several methods to make sure they identify ALL the Causal Factors.

When they have identified the Causal Factors, they aren’t done. They are just getting started.

EACH of the Causal Factors are taken through the TapRooT® Root Cause Tree®, using the Root Cause Tree® Dictionary,  and all the root causes for each Causal Factor are identified.

That’s right. There may be more than one root cause for each Causal Factor. Think of it as there may be more than one best practice to implement to prevent that Causal Factor from happening again.

TapRooT® Investigators go even one step further. They look for Generic Causes.

What is a Generic Cause? The system problem that allowed the root cause to exist.

Here’s a simple example. Let’s say that you find a simple typo in a procedure. That typo cause an error.

Of course, you would fix the typo. But you would also ask …

Why was the typo allowed to exist?

Wasn’t there a proofing process? Why didn’t operators who used the procedure in the past report the problem they spotted (assuming that this is the first time there was an error and the procedure had been used before)?

You might find that there is an ineffective proofing process or that the proofing process isn’t being performed. You might find that operators had previously reported the problem but it had never been fixed.

If you find there is a Generic Cause, you then have to think about all the other procedures that might have similar problems and how to fix the system problem (or problems). Of course, ideas to help you do this are included in the TapRooT® Corrective Action Helper® Guide.

So, in a major accident like the wreck of the USS Fitzgerald, there are probably multiple mistakes that were made (multiple Causal Factors), multiple root causes, some Generic Causes, and lots of corrective actions that could improve performance and stop future collisions.

To learn advanced root cause analysis, attend a public TapRooT® Courses. See the dates and locations here:

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

Or schedule a course at your facility for 10 or more of people. CLICK HERE to get a quote for a course at your site.

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