Root Cause Analysis Tip: Using TapRooT® Proactively
I don’t think there is much debate about the power of conducting a solid root cause analysis when you have an incident, accident or injury. After all, finding and correcting the root cause of an incident will prevent this from happening again, so it would be foolish not to investigate these problems.
In fact, it can be relatively easy to convince management that it makes sense to expend resources to perform these investigation. A simple cost / benefit analysis may be all it takes to paint the picture. If an accident costs us $20,000 in damaged materials, $180,000 in lost production, and an injury that costs $40,000 in medical bills, it makes perfect sense to spend a few thousand dollars to make sure this problem doesn’t happen again.
But how do I convince my boss to spend a few thousand dollars fixing an issue that hasn’t happened yet. That’s a little tougher. You’re asking for resources to be expended for something that you can’t prove is actually going to happen. It’s too bad we didn’t have a crystal ball that could have looked into the future and allowed us to foresee this $240,000 problem. If only I could just look at a situation and know that bad things are going to happen.
Let’s take a look at a problem here and see if we think we could have caught this problem before the incident:
Again, I sure wish we could have seen this one coming.
Well then why do these types of problems happen? All we have to do is open our eyes, and it becomes crystal clear that problems are going to happen if we don’t take action. And yet, we often wait until the accident occurs before we decide we need to fix the these obvious issues. Since TapRooT® works so well finding answers to problems that have already occurred (reactive analysis), it stands to reason it would work just as well finding answers to problems that have not yet caused an incident. We call the Proactive Analysis.
You can use TapRooT® for proactive analysis in almost the same way you would perform a reactive analysis. In this case, you’ll use the TapRooT® techniques to help you perform an audit of a high-risk evolution. In the crane loading example above, we would build a SnapCharT® that shows how we expect this evolution should normally be performed. We would look at the evolution plan and decide what parts of the evolution we want to study. Then we would actually go out into the field and watch the evolution (in this case, the crane loading evolution). We would write down everything we saw during the evolution (both good and bad). Obviously, if we saw something unsafe, we would stop the evolution. In any case, we would then add all of our information to our SnapCharT®, and determine the Significant Issues we saw during the (hopefully) successful evolution.
What are Significant Issues? These are problems that we saw during the evolution that could have caused an incident or near miss. A Significant Issue is very similar to a Causal Factor, except we didn’t actually cause an incident.
And now for the most important part of the process. We can’t just assign a corrective action to a Significant Issue. What are we fixing? We haven’t found root causes yet, so we are just fixing the symptoms of the problem. What we actually have to do is run these Significant Issues through the Root Cause Tree®, just like we do for actual incidents. By finding and correcting these root causes, we are now able to apply corrective actions to the correct problem.
Looking at the crane loading incident, is there any doubt in your mind that, having watched a similar evolution the week before, we could have put solid corrective actions in place and prevented this near-catastrophe? As bad as this incident was, they were only inches from killing someone.
Proactive use of the TapRooT® techniques is the most under-utilized application of TapRooT® in industry. Simple, effective audits, with solid root cause analysis and effective corrective actions, are the analyses with the highest return on investment. Not very expensive; we should be doing these observations anyway. By using TapRooT® to make your observations even more effective, you have the opportunity to save lives with relatively little effort.
As a final note, I enjoyed reading the comments below this YouTube video. It was just “dumb” people. Even after “experts” watched this video, their best answers were to fire everyone, or only stupid people would do this. Therefore, we don’t have to do anything. They were just dumb. Hmmm. Sure wish there was a powerful RCA technique available that would give me better corrective actions …