September 18, 2005 | Mark Paradies

My Ideas About Faster Investigations

How did I answer this question from a client?

We are looking into options of what tool to use for our low level incident investigations. One option at the moment is to look at using a modified TapRooT(R). I am wanting to identify other organizations that use TapRooT(R) for low level incident investigations with a contact name so that I can discuss the issue with them.

Are you able to help?

– – –

Here are my ideas about saving time when investigating “minor” incidents, near-misses, and other small problems… These are a summation of best practices that I have seen implemented by TapRooT(R) Users.

1. First, the best way to save time investigating minor incidents is to STOP investigating things that aren’t worth investigating. So ask yourself the question:

DOES THIS INCIDENT REALLY NEED INVESTIGATING?

In answering this question you should ask yourself:

a. Are the consequences serious enough to be worth the effort of the investigation investment?

b. What will be the return be on my investment in investigation time and effort?

c. Is this an failure that could lead to more serious failures or are the consequence of this failure minor at best?

d. Is this a repeat failure that happens so frequently that stopping multiple repeat failures is worth the investigative effort?

e. Is this some management, regulatory, or public relations “hot button” that may be worth investigating for political reasons?

If the incident is not worth investigating, you should at least record the event in a database so that you can trend the failure type and location. Future data may show an increasing trend of failures or an unacceptable rate of repeat failures.

If you are concerned that you may miss something that really was worth investigating remember: Most investigations done halfheartedly are done so poorly that the real causes are not discovered and the corrective actions are a waste of time and effort. Therefore, investing real effort in fewer investigations will probably lead to faster, better improvements than the same amount of effort spent on more, but poorer investigations.

If you think you should do more to improve performance, invest your effort in proactive observations/assessments/audits that can be targeted to high risk areas and produce even faster, more effective improvements.

So the bottom line is: If it is worth investigating, it is worth finding and fixing the root causes. If it is not worth investigating, DON’T INVESTIGATE IT. Just categorize and trend.

2. Next, if an investigation is worth investigating then it is worth finding root causes and implementing corrective actions to prevent the incident’s recurrence. But not all investigations are created equal. You need to decide the level of effort that you will invest in the investigation. Here are some sample “levels” of investigation:

a. Serious Accident: The level of damage or loss caused by the accident means that this investigation will probably get regulatory, senior management, shareholder, and potentially public attending. The extreme consequences means that this will also be the most difficult type of investigation. This type of investigation will take a dedicated team of highly trained company investigators and consultants to conduct a thorough review of all evidence. The complete suite of TapRooT(R) Techniques will be employed. A considerable investment in time and resources will be required as well as senior management review or the investigation results and potentially an independent review by a highly experienced outside reviewer. This is obviously NOT they type of investigation imagined by this question.

b. Serious Incident: The level of damage or loss caused by this incident is worthy of investigation and root cause analysis. This incident is serious because it cause damage just below that required to trigger a “Serious Accident” investigation or because it could have easily caused a Serious Accident with slightly different circumstances or without the intervention of luck. This investigation will be similar to the investigation above with the exception that some of the team members may be slightly less experienced, less consultants will be used, and the review of the investigation will be by local management and an investigation peer review committee made up of local investigation experts. Once again, this investigation is above the “minor” investigation posed by the users question.

c. Incident: This incident caused minor damage or loss and there was at least one significant safeguard (which was NOT luck) to keep the incident from becoming a Serious Incident. In this case, a single investigator or a small investigative team may be used to perform the investigation and only two tools will be used to perform the investigation: SnapCharT(R) and the Root Cause Tree(R). These types of incident investigations will receive a brief review by the peer review committee but will not receive management review unless a trend is detected. Ideas presented below will be used to save time and effort in these investigations

d. Recordable Event: These events are judged to NOT be worthy of investigations. The type of event, organization, and the location are recorded in a database to allow trending. Since no investigation is performed, no corrective actions are recommended and future recurrence of the event is possible. Trends will be used to detect significantly increasing frequency of these events.

A tip for the nuclear industry. All “significant conditions adverse to quality” should be rated as an incident or above and therefore deserve root cause analysis. If it is not a significant condition adverse to quality and it is not in another category that makes it significant (cost, delayed startup, personnel injury, non-nuclear environmental release, …), then you should categorize it and NOT waste time doing some sort of halfhearted “Apparent Cause” evaluation that will waste time and corrective action effort implementing fixes that aren’t effective.

3. There are several ways investigators can save time in performing minor investigations of incidents that just barely make the cut for the “incident” category above. Here is a short list of the more beneficial ideas I’ve heard:

a. Training and Practice: The best way to waste time and effort on investigations is by using untrained, inexperienced investigators. The more investigations an investigator performs, the better and FASTER they become. The best way to gain experience at the least cost is by performing proactive investigations and by participating as junior members of investigation teams investigating more serious incidents. Also, the more training you can afford, the better investigator you will be. People who take the 5-Day TapRooT(R) Course get more experience in the course and are better and faster investigators than those who attend the 2-Day TapRooT(R) Course. And of course the 2-day trained investigators are better than untrained investigators. Those who attend the TapRooT(R) Summit get even more training in the Advanced Investigation Skills Track, the Human Performance and Behavior Change Best Practices Track, or the Equipment Reliability and Maintenance Best Practices Track. All your investigators should be continually improving their skills and thereby become better, faster investigators.

b. Spring SnapCharT(R): The most time consuming part of an investigation is the collecting information needed to draw a good SnapCharT(R). A little pre-planning can go a long ways to save time in an investigation. First, draw a preliminary SnapCharT(R) to get started. This will help you decide where you have missing and conflicting information. You can plan where you need to look to find more information. You can avoid wasting time looking for information that isn’t applicable to your investigation.

c. Lunch Meetings: Hold three 30 minute “lunch meetings” to perform a rapid investigation of an incident. The company provides the lunch (pizza, sandwiches, …) for the attendees and they supply the help an investigator needs. The first 30 minute meeting is held to get a complete Summer SnapCharT(R) drawn. A single investigator can put this SnapCharT(R) built using Post-It Notes into the TapRooT(R) Software in about 30 minutes. Or you can train an admin person to do this for the investigator and save even more time. The investigator will also identify the Causal Factors (time spent 30-45 minutes). Then the investigator can hold another lunch meeting to review the SnapCharT(R) and Causal Factors with those involved to get agreement that the chart and Causal Factors are accurate (30 minutes). After this meeting, the investigator then takes the Causal Factors through the Root Cause Tree(R). The investigator does NOT go “circle happy (circling every possibility that could have contributed to the incident) but rather ONLY identifies the root causes that indisputably will prevent the recurrence of the incident if they are corrected. The investigator should take no more than 10 to 15 minutes per Causal Factor in going through the Root Cause Tree(R). On average for minor events (with just 2 or 3 Causal factors), this should take about 30 to 40 minutes. The investigator then holds a third lunch meeting with the right people (perhaps some additional attendees) to develop effective corrective actions (with the help of the Corrective Action Helper(R) module of the TapRooT(R) Software. Finally, the investigator takes an addition 30 minutes to 1 hour to finish the documentation in the TapRooT(R) Software and initiate any work orders required to implement corrective actions. Total investigator time spent – about 3 to 4 hours. The time required for other participants is limited to the three 30 minute lunches. Since this time was also spent eating lunch, there is essentially no cost (besides the cost of lunch) for this time.

d. Skip Generic Root Cause Analysis: When Causal Factors are taken through the Root Cause Tree(R), Specific Root Causes are identified. The next step in the TapRooT(R) process is to check to see if there are Generic Causes for the Specific Root Causes. For less serious investigations, the investigator can skip this step. The identification of Generic Root Causes for the more minor investigations can be left for the trending system to identify.

e. Reduced Review: All investigation that are going to have root causes recorded in the database and corrective actions should have a peer review. For minor investigations this peer review should be limited to 15 minutes. additional investigation or changes in corrective actions should be allowed for only the most glaring errors. Instead, this review should be focused on providing feedback to the investigator to improve their skills (an thus make future investigations better and faster). The peer review should comment about what was good about this investigation and what could be improved in future investigations and corrective actions. A timer should be used to insure that the review does not take more than 15 minutes.

f. Trained Supervisors: One major slow down in investigations is trying to piece together or recreate evidence that was destroyed before the investigator arrives. Broken parts are cleaned up and thrown away. Records are misplaced. Souvenirs are taken by onlookers. Witnesses depart or confuse their observations by having discussions with others. To prevent this loss of basic evidence, supervisors, who might be the first to arrive on the scene after and accident or incident, should be trained to collect and preserve evidence. This can save hours, days, weeks, or months from an investigation. Or it might make an investigation possible when otherwise, with lost or contaminated evidence, it would be impossible.

g. Trained Management: A true waste of investigative effort and time is presenting investigations to management and have them send the investigator back to do more investigation or change reports because the managers do not understand root cause analysis or how it can help them improve performance. This is especially true when management does not understand that by finding and correcting Management System causes, investigations can make major improvements in the way a facility is managed and potentially save manager’s jobs (by avoiding a major accident). Management can also cause time to be wasted by insisting on mini-root cause analysis for events that don’t deserve investigations, assigning untrained investigators to perform investigations, requiring reports in too little time (“Have it on my desk in the morning.”), or not insisting on good root cause analysis (instead they accept poor investigations with what seem to be easy to implement – but ineffective – corrective actions.

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Investigations
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