Precursor Incidents – Why the TapRooT® Folks Want You to Sweat the Small Stuff
Resolve Precursor Incidents Before They Become Worse
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System Improvements, Inc. (aka 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® President Mark Paradies observes:
“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.”
Success Story: 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. See the company’s success story for a more detailed description of its results.
Watch the Video: “How to Avoid Big Problems by Paying Attention to the Small Stuff”
Listen to TapRooT® professionals Mark Paradies and Benna Dortch discuss on TapRooT® TV “How to Avoid Big Problems by Paying Attention to the Small Stuff”—in other words, investigating precursor incidents with the focus on keeping major incidents from occurring.
Learn More 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 the book set at the TapRooT® Store.
Or, better yet, 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.
See the list of upcoming public 2-Day TapRooT® Courses.
Why TapRooT® RCA?
First, TapRooT® has an extensive development history and is being continuously improved. (See a brief description of the TapRooT® History.)
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.
Have any questions? Please call us at 865.539.2139.
Gather a Wealth of Knowledge and Experience at the 2020 Global TapRooT® Summit
One more thing. Don’t forget to register for the 2020 Global TapRooT® Summit, where you will network, learn from industry leaders and performance experts, and profit from success stories and root cause analysis best practices across industries and professions. The Summit is March 9 – 13, 2020, at Horseshoe Bay Resort, near Austin, Texas.
At the 2020 Global TapRooT® Summit, you will grow from these experiences:
- Incredible keynote speakers
- Register for a 2-Day Pre-Summit Course, offered March 9 – 10, 2020
- Meet industry leaders and other professionals at the Reception, Wednesday, March 11, 2020
- Sharing and Implementing takeaways from track leaders and speakers when you return to your organization