Are You Using TapRooT® the Right Way for Simple Incident Investigation?
Is that diagram your root cause system for simple incidents?
Every once in a while I have someone tell me that they only use TapRooT® Root Cause Analysis for major accidents. When I ask why, they tell me that TapRooT® is “too hard” for simple investigations. That’s when I know we need a more in-depth conversation.
First, I ask:
”Is preventing major accidents important?”
Of course, 99% of the time the answer is: “Yes.”
Then I ask about how they plan to prevent them …
The answer usually gets around to learning from PRECURSOR INCIDENTS. Learning from these near-misses that could have been major accidents if a couple more Safeguards had failed is critical to understanding what could go wrong, what could cause those major accidents, and what Safeguards are working (what went right).
Once we establish that learning from these precursor incidents is critical, I ask:
“What is the minimum investigation required to really understand
and fix the causes of these precursor incidents?“
That’s a tougher question. But I’ve previously written an article about it and you can read it HERE.
That’s when the person replies …
“I didn’t know there was an easy way to apply TapRooT® –
I though you always had to do the whole seven step process!”
Probably the biggest simplification in the simple way to use TapRooT® is to STOP the investigation after you do your initial information gathering and draw your initial SnapCharT®.
If you find there really isn’t anything important to learn from this investigation … Just STOP.
Second, if you continue with one of these simple investigations, you use a limited set of tools and you skip the Generic Cause Analysis. This reduces effort considerably.
Finally, in major investigations, you usually have a team do the investigation and have a major management presentation. In a simple investigation, a single individual usually performs the investigation and their work is reviewed by an expert facilitator and then informally approved by the appropriate manager.
Want to learn more about using TapRooT® for simple investigations? The read: