February 4, 2010 | Barb Carr

Root Cause Analysis Tip: Part 2: Behind Closed Doors with A Common Sense Discussion

Part 2, as promised, is a discussion on our TapRooT® Users and Friends LinkedIn Group.  This begins with a question asked by Jason Laws, a plant manager and client. Join us if you want to get into this conversation or even just to contact Jason directly.


“Common Sense, the Root Cause Tree and a perceived recent lack in the up and coming work force that I have noticed”

My Production Supervisor asked me the other day if there was a place in the root cause tree for Common Sense. I actually said, I didn’t think so. That when we come across “a common sense” causal factor the root causes are usually identified in a Management Systems, Training, and Procedures…. I may really be wrong there….I hate to think it would be in work direction and I am running into more and more unqualified candidates.

Where I have struggled recently is with this very idea. Some things, it would never have occurred to me that we would need to drill training down to that level.
(It was common to police up your work site at the end of a job. When cutting you always cut away, use the right tool for the right job, there is very little in the world that is fit to bang on other than nails, use a chalk line and plumb bob to put up a line of pipe supports, place the labels on the totes level and neatly, check the breaker when the pump won’t start, ….These are just the ones that have come to mind but the list continues.) [ I don’t put in don’t dead head or run a pump dry. I’ve been doing this too long to expect that.]

That does bring me to one point I have tried. That is the Poke Yoke or “Error Proof” things. All pumps go in with a Power Monitor shut off now. You can’t run it dry or dead head it.

Still, I am with my Production Supervisor…and have had the same conversation with my Maintenance Director. Is there a place for Common Sense in the root cause tree? Am I the only one? Is the work force changing? Has Nintendo killed the opportunity to get the basic knowledge I and others did with chores, play, hobbies and jobs when were young? If so, what can be done? If the answer is drill spac, training and procedures deeper down into the core knowledge, how do you know how far and how to you identify knowledge that you take for granted that really isn’t.

Sorry, if that was a bit of a ramble, but the Production Supervisor really got me curious.

Thanks All,


Now the rest of the discussion from the TapRooT® Users and Friends LinkedIn Group

Response from: Christopher Vallee, Senior Associate and TapRooT® Instructor

ah…back to the when I was young, I walked up hill to and from work and pushed double the product you youngin’s push out and with no mistakes!

First off Jason you are right, many of the new employees of today have different skills sets than us old folks…. of course they would tell us it was “common sense” not to upgrade your software with out….etc… AFTER we locked up our computer. After all, didn’t we know this was not compatible for this computer.. duh!

At the same time the craftsman-apprentice relationship from years back no longer exists in many industries. Often it is the junior employee training the junior employee. The senior experienced employee is too busy fixing things to train anyone and often retires without documenting what s/he knows from experience.

The thought that any worker selection process, training process, and mistake-proofing remain stable and does not need to be flexible is a myth. Look at job descriptions, many are outdated, impacting the hiring process and training process.

First attack at the problem:

1. Identify the core skills needed by the employee to perform the core critical tasks for her/his job. Look up AMOD/ DACUM

2. Identify where the employees actually get the needed training. Often training programs get stuck looking at just missed appointments and regulatory required training, thus losing contact with the how the training impacts operations. (Where did the senior workers get their knowledge?)

3. Review the employee’s supervisor’s skill’s and training as well. Often new managers are hired based on needing to have a degree but never get the technical training listed above. The employee then asks the supervisor is this good enough…. how would s/he know?

4. If the training program is outdated (or just broke), then temporarily bring in a knowledgeable mechanic that has a retired and let them help revamp the new program with hands on training.

So if the employee needs a mechanical aptitude to perform certain jobs, then why was s/he not tested prior to hiring? After all, what happened to the unskilled in years past if s/he could not meet the aptitude need? S/he was either trained or kicked out the door.

After all, if common sense where the answer, you would not need the root cause tree either. So GOAL (go out and look) to find what the core skills and tasks are and then ensure that these requirements are met. Also see what you can learn from the new employees as well.

Posted 1 month ago | Delete comment

Response from: Kenneth Reed, Senior Associate and TapRooT® Instructor
You’re right, Jason. There is no Root Cause labeled “common sense NI” anywhere on the Root Cause Tree®. Just like there is no “attention to detail NI” or “operator error.” Although they initially seem like root causes, in reality they are just a convenient way to shift blame.

For example, if I told you the Root Cause was “common sense NI,” what would be your Corrective Action? How do you fix “common sense?” You can’t! Just like you can’t fix “inattention to detail” or ” operator error.” Therefore, we would default to poor Corrective Actions like, “Counsel the employee on using common sense when using a knife.” Completely useless Corrective Action, with almost no hope for better performance.

Instead, we need to look a little deeper at the problem. This is what Chris was alluding to above. Why did the operator slice his hand open? Was it really just a common sense problem? Or is there something we as management can do to prevent this issue?

That’s where the 15 questions, the Dictionary®, and the Root Cause Tree® come in. We need to ask ourselves the questions on the tree to dig deep enough into the problem. Instead of asking, “why didn’t this guy use common sense when cutting that wire, and cut away from himself?”, maybe we should ask:

– Was the worker fatigued, impaired, upset, bored, distracted, or overwhelmed?
– Was he using the right tool? Did we provide him with the right tool?
– Was the right person performing this job?
– Was this job really required in the first place?
– Do supervisors ever watch their people do this particular job? Why not?
– Would a supervisor have stopped this evolution before an injury occurred? If so, why didn’t he? If not, why not?
– Was the worker properly trained for this task?
– since I’m sure the worker did not intend to cut himself, what lead him to think doing the job in this manner was OK?

I could go on, but you get the point. When you find yourself saying, “This was just a dumb person, not using common sense, just a simple human error that I have no control over,” it’s time to step back and let the system work for you. Let the Root Cause Tree® and Dictionary® help you ask the right questions.

I also know that sometimes we think that people should already know these things. There are 2 possibilities:

1. The person really didn’t know (to cut away from himself)
– Therefore, this is a training issue
2. The person DID know, but chose to do it anyway.
– This is when my discussion above comes into play.

Hope this helps a little.

Posted 1 month ago | Reply Privately | Delete comment

Response from Jason:
Thanks Chris and Ken. One thing I have been trying to do, and encouraging my people to do (though finding the resources is always the challenge) is to use TapRooT® in audit mode.

I have worked the tree through these issues and developed corrective actions to account….mainly training, human engineering and Management systems.

My frustration can come from I just haven’t seen or anticipated the lack of knowledge in the first place to head it off at the pass. I am not even sure some of these issues would have occurred to me if I was putting together an audit SnapChart®.

Thinking on this thread, maybe the broader use of CHAPs might catch some of this. In a resource starved environment, I am trying to bring the tools I have to the best and most efficient use.

So, with GOAL. Maybe an Audit SnapChart®, the 15 questions, a CHAP and the Dictionary® I prevent some of these.

The struggle that remains is to overcome the blind spot of assumptive experience and figure out what needs to be trained for in the first place. What are the things we take for granted that really aren’t.

Once again. Thanks guys. I appreciate the feedback.

Posted 1 month ago | Reply Privately | Delete comment

Response from: Christopher Vallee, Senior Associate and TapRooT® Instructor

Music to my ears Jason…. “proactive CHAP”. When people are first introduced to Critical Human Action Profile, they look for critical steps in a task that if skipped, done wrong, or in the wrong sequence, could have caused the incident or made it worse. A proactive audit can look for steps that are critical to safety and process.

As far as the “blind spot for assumptive experience”, this is a generic issue as you have described it. So what system should be controlling the hazard of having unskilled employees on the shop floor (or in the field)?

Steps of the process:

1. Company or Contractor Human Resources hire employees that have the skills and capabilities to perform their assigned core tasks.

Problem: Metrics that HR are usually measured by for the hiring process are retention and number of new employees. No tie made to direct labor and rework.

2. Training department has a structured training program that uses classroom and hand’s on training for the cores tasks (process and regulatory).

Problem: Training is often measured by Number of missed appointments and upkeep of regulatory training. No tie made to direct labor and rework costs.

3. Shops have floating experts identified for employees who need a little help.

Problem: The new are training the new. The senior employees are too busy to.

So ask your HR department and your training department, how do they know that they have been successful when hiring and training a person? Most likely it will not be tied to operations ROI. .

Have senior employees attend training with new employees to help all do right.

Look at your critical job’s and tasks to determine what skills and capabilities should be covered for each person and then use GOAL to identify what is missing.

Posted 1 month ago | Delete comment

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