October 21, 2009 | Barb Carr

Root Cause Analysis Tip: Have you done your TapRooT® Homework?

Trending positive or negative changes in safety is less about the numbers than you may think. To put it simply, if I do not know….

… where the number come from?
… what the number (baseline) used to be?
… what I changed to get a different number?
… who got the number for me?
… what does the number have to do with risks?

..then I might as well just report LTI’s and incidents only and hope things will get better. So what could I do to help me? Start with something I have in front of me right now, TapRooT® Categories:

Departments: Do you assign departments in your software by area of responsibility or area of risk (accident location)? Hint: Location by area of responsibility already shows up next to the names you assign to the incident.

Classifications: Do you just have “Incident”, “Near Miss”, and “Violation” as categories or do you have Injury, process hazard, and customer issues as well listed in the incident classification section? Hint: you can select more than one classification at a time in the software for each incident. This would allow you to pick type of hazard and type of incident at the same time.

Risks: Have you listed the actual hazard in each Causal Factor instead of just the error? Hint: Mechanic did not close valve (Hazard: Uncontrolled Pressure). You could then chart each type of hazard. Trying to trend by type of error does not work as well unless investigators write their causal factors the same exact way. For example, mechanic left valve open would not be grouped in with mechanic did not close valve.

The point is you must understand the processes that your safety metrics are trying to measure. You should be able to proactively measure what you changed and see what impacted your LTI’s. Doing your homework helps you assign where your critical resources (people and equipment) need to be assigned before something bad happens. Numbers are just numbers without meaning.

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