September 11, 2019 | Mark Paradies

Is Human Error a Root Cause? (Updated)

Does a Human Error = a Root Cause?

A frequent question that I see in various on-line chat forums is: “Is human error a root cause?”

For TapRooT® Users, the answer is obvious … NO!

Human error is probably a Causal Factor. (See the definition of a Causal Factor here).

But the amount of discussion that I see and the people who even try suggesting corrective actions for human error with no further analysis is amazing. Therefore, I thought I’d provide those who are NOT TapRooT® Users with some information about how TapRooT® can be used to find and fix the root causes of human error.

Define a “Root Cause”

First, we must define a root cause. Our definition is:

The absence of a best practice or the failure to apply
knowledge that would have prevented a problem
.”

For the history of our definition of a root cause, see:

https://www.taproot.com/the-history-of-the-definition-of-a-root-cause/

But we went beyond this simple definition. We created a tool called the Root Cause Tree® to help investigators go beyond their current knowledge to discover human factors best practices/knowledge to improve human performance and stop/reduce human errors.

Analyze a Human Error Using the Root Cause Tree® Diagram

How does the Root Cause Tree® work?

First, if there is a human error, it gets the investigator to ask 15 questions to guide the investigator to the appropriate seven potential Basic Cause Categories to investigate further to find root causes.

An example of one of the 15 questions is:

The 15 questions lead you to one or more of the seven Basic Cause Categories. The seven Basic Cause Categories are:

  • Procedures,
  • Training,
  • Quality Control,
  • Communications,
  • Human Engineering,
  • Work Direction, and
  • Management Systems.

If a category is indicated by one of the 15 questions, the investigator uses evidence in a process of elimination and selection guided by the questions in the Root Cause Tree® Dictionary.

The investigator uses evidence to work their way down the tree until root causes are discovered under the indicated categories or until that category is eliminated. Here’s the Human Engineering Basic Cause Category with one root cause (Lights NI).

Screen Shot 2014 07 08 at 10 35 20 AM

The process of using the Root Cause Tree® was tested by users in several different industries including a refinery, an oil exploration division of a major oil company, the Nuclear Regulatory Commission, and an airline. In each case, the tests proved that the Tree helped investigators find root causes that they previously would have overlooked and improved the company’s development of more effective corrective actions. You can see examples of the results of performance improvement by using the TapRooT® System by seeing the Solutions – By Industries tabs above (each industry has a different success story).

Fixing Human Error Root Causes

How do you fix a human error related root cause? The answer is in the Corrective Action Helper® Guide. For each human error related root cause on the RooT® Cause Tree®, Mark Paradies and a team of experts have devised the best answers for fixing that type of problem. You can get the Corrective Action Helper® Guide when you order either the book: Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents, or the book: Using TapRooT® Root Cause Analysis for Major Investigations, or when you by both books as a set.

What does the Guide have to say about solving lighting problems? Here are segments from the Corrective Action Helper® Module of the TapRooT® VI Software (the computerized version of the guide:

You start by checking that you are fixing an actual root cause.

Next, it provides ideas for you to consider to improve lighting.

It then provides ideas for correcting Genric Causes (problems across the facility or company).

Finally, it provides you with references to learn more about lighting.

Would that help you are your folks develop more effective corrective actions to human performance issues?

Learn More About Root Cause Analysis of Human Errors

If you would like to learn to use TapRooT® and the Root Cause Tree® to find the real root causes of human error and to improve human performance, I suggest that you attend our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course and bring an incident that you are familiar with to the course to use as a final exercise.

Note that we stand behind our training with an ironclad guarantee. Attend the course. Go back to work and apply what you have learned. If you and your management don’t agree that you are finding root causes that you previously would have overlooked and that your management doesn’t find that the corrective actions you recommend are much more effective, just return your course materials and software and we will refund the entire course fee. No questions asked. It’s just that simple.

How can we make such a risk-free guarantee?

Because we’ve proven that TapRooT® works over and over again at industries around the world. We have no fear that you will see that TapRooT® improves your analysis of human errors, helps you develop more effective corrective actions, and helps your company achieve the next level better level of performance.

Also, watch for the new book coming out this winter titled:

Stopping Human Error

It will teach you many ways to analyze and reduce or stop human error.

 

Note: Sections of the Root Cause Tree® and the Corrective Action Helper® Guide above are copyrighted material and are used here by permission. Duplication is prohibited.

Categories
Human Performance, Root Cause Analysis, Root Cause Analysis Tips
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