October 2, 2009 | Ken Reed

Root Cause Analysis and Poor Decisions

“I’m sure my guys wouldn’t check a petroleum storage tank gas-free with a lit welding torch…”
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“I’m sure my guys wouldn’t purge a natural gas line into an enclosed space inside the building…”
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People make poor decisions all the time.  In hindsight, it sometimes looks like these people “just weren’t thinking.”  However, the opposite is usually true.  Poor decisions are usually made after some type of internal risk analysis, often with many variables considered:

– I’ve never had a problem with this before
– This will only take a minute
– It’s not really that dangerous
– I’m more careful than the normal person

This thought process may only take 3 seconds, but it does occur.  What we need to do is figure out what made this decision OK in the minds of the people performing the evolution. 

– What made this poor decision acceptable to the worker?
– Did management condone these decisions in the past?
– What safeguards are, or should be, in place to prevent this decision from being implemented?
– What do we have in place to help our workers make the right decisions?

Performing a root cause analysis using TapRooT® will help you understand why we do these “dumb” things, and put in place solid corrective actions to prevent the problem from happening again.

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