Root Cause Analysis Tip: Investigations – TapRooT® Optional Techniques
- Change Analysis
- Critical Human Action Profiles (CHAP)
- Safeguards Analysis
This tool can really help focus you on why a particular incident or problem happened this time, when we actually perform that process all the time. Just by asking yourself, “What was different this time, compared to how we always do it?” can help focus you on the specific circumstances of the investigation. Did we do something differently? Were there different initial conditions? What were the environmental conditions this time? Who normally performs this job? What’s special about this piece of equipment compared to all the other ones in the plant? Using the formal Change Analysis tool can help you focus on these aspects of the investigation.
Critical Human Action Profile (CHAP):
I use this tool most often when it looks like there was just a “simple” mistake. For example, someone was packing a box and sustained an injury. CHAP is used to look at exactly how we performed a job, down to the most minute details. It is similar to a Job Task Analysis. What tools, initial conditions, training level, supervision, PPE, etc were required to perform each particular step of the job?
I use this tool most often when I’m identifying Causal Factors. By using Safeguards Analysis, I can more easily identify why a person might have had diffiiculty performing an action, or why they did it differently than intended. I also use it when analyzing a “simple” mistake. When someone gets hurt, or we do something contrary to company policies, it is often because we have a problem with the safeguards that were (or should have been) in place. By using Safeguards Analysis, you can more easily identify these problems, giving you a much better understanding of what actually lead to the mistake.
Equifactor® Equipment Troubleshooting Tables:
These tables are a terrific resource for your maintenance and repair teams. When they have run out of ideas as to the “physical” cause of an equipment failure, they can turn to Equifactor® to give them a comprehensive list of possible causes for the failure symptoms they are seeing. Using Equifactor® can save your team hours of “easter-egging” to find the problem. And once they discover the actual physical cause of the failure (“the bearing failed because we used the wrong grease”), they can plug that back into their summer SnapCharT® and use the rest of the TapRooT® process to get to true root causes of the failure.
This is just a brief description of these optional tools. While they may not be required on every investigation, you should evaluate if you need them each time. Using these tools may give you the additional insight you need to prepare more comprehensive SnapCharT®s, leading to better corrective actions in the end.
Ken Reed is a Partner at System Improvements, Inc.