Have a Plan! Using the TapRooT® Tools to Plan Your Investigation
Sometimes, it seems like the toughest part of an investigation is figuring out how to get started. What’s the first step? Where am I headed? Who do I need to talk to? What questions should I ask?
Unfortunately, most systems kind of leave you hanging. They assume that you’re some kind of forensic and investigation expert, with years of psychological and interviewing training already under your belt. Like you’re only job at your company is to sit around and wait for a problem to occur so that you can perform an investigation!
Luckily, TapRooT® has some great tools that are designed to walk you through an investigation process. We have recently tweaked this guidance to make it even easier to quickly progress through the investigation. Some of the tools are used for every investigation; some are used only in specialized circumstances when you need additional help gathering information.
Some of these tools are required for every investigation; some are optional data-gathering tools. Let’s first take a look at the required tools.
One of the first things you need to do is get a good understanding of exactly what happened. Instead of just grabbing a big yellow legal pad and start scribbling down random thoughts, you will use the SnapCharT® to build a visual representation and timeline of what actually occurred. By putting your thoughts down on the timeline, you can more easily see not only what you already know, but also what you still need to find out. It helps you figure out what questions to ask and who to ask. Building your SnapCharT® is ALWAYS the first step in your investigation for just this reason. There is no reason to go into the interview process if you don’t already have a basic understanding of what happened and what questions you need to ask. It’s really amazing to see a group of people start building a SnapCharT®, thinking they already have a good understanding of the issues, and watch them suddenly realize that they still need to ask a few pointed questions to truly understand the problem.
Root Cause Tree®:
Most TapRooT® users know that the Root Cause Tree® is used during the root cause analysis steps in the process. However, this tool is a treasure trove of terrific questions and guidance that can be used while building your SnapCharT®. In conjunction with the Dictionary®, it contains a comprehensive list of interview questions; the same questions that a human performance expert would ask if they were performing this same investigation. You’ll need the answers to these questions once you get to the root cause analysis phase. Why not “cheat” a little bit and ask these questions right up front while building your SnapCharT®?
The tools I listed above are used during EVERY investigation. However, in certain circumstances, you may need some additional guidance and data-gathering tools to help build your SnapCharT®. Let’s look at the non-required tools.
Change Analysis: This is a great tool to use to help you ask thought-provoking questions. It is used when either something is different than it used to be, or when there is a difference between two seemingly identical circumstances. The Change Analysis tool helps you determine what would have normally made the situation operate correctly, and (this time) what allowed the problem to show up under the exact circumstances of the incident. It is actually an extremely easy tool to use, and yet it is very powerful. I find this to be my most-used optional tool. The results of this analysis are now added to your SnapCharT® for later root cause analysis.
Critical Human Action Profile (CHAP): Sometimes, you need help understanding those “dumb” mistakes. How can someone be walking down the stairs and just plain fall down? The person must just be clumsy! This is a great time to use CHAP. It allows you to do an in-depth job task analysis, understanding exactly what the person was doing at each step in the task. What tools were they using (and supposed to be using)? How did we expect them to perform the individual steps in the task? This tool forces you to drill down to a very detailed analysis of exactly what the person was doing, and also should have been doing. The differences you find will be added to your SnapCharT® to help you understand EXACTLY what was going on.
Equifactor®: If your investigation includes equipment failures, you may need some help understanding the exact cause of the failure. You can’t really progress through the root cause analysis unless you understand the physical cause of the equipment problem. For example, if a compressor has excessive vibration, and this was directly related to your incident, you really need to know exactly why the vibration was occurring. Just putting “Compressor begins vibrating” on your SnapCharT® is not very useful; you have to know what lead to the vibration. The Equifactor® equipment troubleshooting tables can give your maintenance and reliability folks some expert advice on where to start looking for the cause of the failure. These tables were developed by Heinz Bloch, so you now have the benefit of some of his expertise as you troubleshoot the failure. Once you find the problem (maybe the flexible coupling has seized), you can add this to your SnapCharT® and look at the human performance issues that were likely present in this failure.
The TapRooT® System is more than just the Root Cause Tree® that everyone is familiar with. The additional tools provided by the system can give you the guidance you need to get started and progress through your investigations. If you need some help getting started, the TapRooT® tools will get you going! Learn more in our 2-day TapRooT® Incident Investigation and Root Cause Analysis Course.