Precursor Incidents – Why the TapRooT® Folks Want You to Sweat the Small Stuff
Resolve Precursor Incidents Before They Become Worse
System Improvements, Inc. (the TapRooT® Root Cause Analysis Folks) has been emphasizing root cause analysis and effective corrective actions for precursor incidents to help improve safety performance since the early 1990s.
What is a precursor Incident? In a previous article, we defined a precursor incident as:
Minor incidents that could have been a major accident
if one or two more Safeguards would have failed.
Why is a precursor incident investigation important?
If another Safeguard fails, if the sequence is slightly different, or if your luck proves worse, the precursor incident becomes a major accident, a fatality, or a significant injury. Thus, a precursor incident’s potential consequences are high. Precursor incidents are sometimes called “HiPos” (High Potential Incidents) or “potential SIFs” (Significant Injury or Fatality).
TapRooT® Codeveloper, Mark Paradies, observed:
“I’ve never seen a major accident that wasn’t preceded by one or more precursor incidents. I’ve never talked to a senior manager that thought a major accident was acceptable. Most claim they are doing everything possible to prevent them. However, many senior managers don’t require advanced root cause analysis for precursor incidents. Thus incidents that don’t have current major consequences are classified as a low consequence event and only receive a cursory review. People ask “Why?” multiple times then implement ineffective corrective actions. Sometimes these minor actual consequence (but high potential consequence) precursor incidents aren’t even reported. Management lets these precursor incidents continue (repeat) until a major accident happens. Then it’s too late. You can’t turn back the hands of time.”
ROI on Precursor Incident Investigation
Small precursor investigations pay off for companies who learn to analyze and fix them by using TapRooT® Root Cause Analysis. A TapRooT® client, an underground coal mining company, was experiencing two to three fatalities a year. The company decided to change its approach to safety and apply TapRooT® to find the root causes of precursor incidents and serious accidents. They developed effective fixes and experienced major improvements – no fatalities for the next three years. For a more detailed description of their results, see:
Learn About Using TapRooT® to Investigate Precursor Incidents
How can you learn to apply TapRooT® to investigate precursor incidents? Read Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents. Order a copy at:
EVEN BETTER, get the book when you attend the 2-Day TapRooT® Root Cause Analysis Course. The course teaches the essential tools needed to quickly investigate a precursor incident, find the incident’s root causes, and develop effective corrective actions. The essential TapRooT® techniques include:
- The SnapCharT® Diagram: a simple, visual technique for collecting and organizing information quickly and efficiently.
- The Root Cause Tree® Diagram and Dictionary: an easy-to-use resource to help investigators find root causes that they previously would have overlooked.
- The Corrective Action Helper® Guide: helps people develop corrective actions by seeing outside the box.
To see the list of upcoming public 2-Day TapRooT® Courses, CLICK HERE.
Why TapRooT® RCA?
First, TapRooT® has an extensive development history and is being continuously improved. (See a brief description of the TapRooT® History HERE.)
Next, are the results that industry leaders are achieving in a wide variety of industries around the world. In a word – impressive. Click on the SOLUTIONS and then the INDUSTRY tabs above. Pick an industry and learn about a company’s success story.
Then, there is the software. Take a great system and make it even easier to use with great software.
Finally, there is a worldwide network of TapRooT® Users. We have a LinkedIn Group and an annual Global TapRooT® Summit where TapRooT® Users gather to share new ideas and best practices. You won’t find a better peer group interested in root cause analysis and performance improvement. The network will help you learn and solve problems.
Don’t Settle for Less Than the Best Root Cause Analysis
Some people settle for an easy, but ineffective RCA tool. They ask “Why?” or build a Fishbone Diagram. They do this because they don’t realize how important developing effective fixes for precursor incidents are. They doom their facility to future major accidents.
You don’t want to make this mistake. You need to be an effective problem-solver. You need TapRooT® Training.
DON’T WAIT! Get registered for a TapRooT® Class today. Pick from one of these upcoming public courses:
2-Day TapRooT® Training
5-Day TapRooT® Training
Or see the worldwide list of upcoming public courses at this link:
If you have any questions, please call us at 865-539-2139.