April 1, 2009 | Dan Verlinde

Root Cause Analysis Tips: Play Ball!







The System Improvements softball team kicked off its inaugural season Tuesday night with a 15-0 victory.  The victory came after the mercy rule was invoked after 4 innings of play.

The performance was a collaborative team effort with notable highlights provided by Sarah H. and Andy C. hitting back to back home runs in the third inning, and Jason H. pitching a shutout (a rare accomplishment in slow-pitch softball).

The shutout was aided by solid defense, with no fielding errors to report.  This of course made me VERY happy given that this is a TapRooT® sponsored team, and I am told that all errors may require a full incident investigation.




Am I filling out the roster or drawing a Spring SnapCharT®? You decide.






While that last part might be a joke, it does provoke some interesting questions.  While I am sure many of you read this blog for the latest information on how the System Improvements softball team is performing, I am sure MANY MORE of you read it to stay informed and up-to-date on incident investigation and root cause analysis.

Investigators need to keep their brains trained on how to perform investigations even when (hopefully) there are no incidents to investigate!  We need to be vigilant and proactive in sharpening our skills and polishing our abilities.

Does that mean that sometimes we view ordinary occurrences outside our workplace through Investigator’s goggles?  Yes, it probably does.  After all, we have conditioned ourselves to investigate, isolate and ultimately fix problems.  Whether it is a car accident, a broken refrigerator, or an error in a softball game, we probably all are guilty of taking our work home with us.

So to illustrate the point, take a look at a hypothetical softball game error (double click on image to view larger)…





The interesting thing here is that we isolated TWO causal factors (problems) in this scenario.  An official softball scorer would record this as a throwing error by the shortstop (E6).  The official scorer would have been only partially right; the shortstop did commit an error.  But how can we fix that?  Discipline the shortstop (bench him)?  Perform more training (practice)?

No shortstop, at any level of play, is error-proof.  Just like any human error, we cannot eliminate it entirely no matter what we try.   This is why there should have been a safeguard in place.  The Right Center Fielder should have been backing up the throw to second, but was out of position causing the ball to roll to the fence.

Keep in mind that when we look for causal factors we aren’t just looking for direct causes, but also things that can significantly reduce the severity of the incident.  In this case, if the Right Center Fielder was in position to back up the Shortstop’s throw, then the base runner would not have scored (thus reducing the severity of the error and preventing a run from scoring).

Softball, like investigations, requires a team effort and every participant needs to be in position and doing their job on every play.  Any good manager (or investigator) will tell you that these safeguards are what can make a good team, a great team.

To obtain more information on TapRooT® Web Enterprise Software Version 5.1.2 BETA used to create the above SnapCharT®,  email us at techsupport@taproot.com

Have a story on how you have used TapRooT® outside of work?  Let us know in the comments.

To see how happy a team looks after winning their first game, see below


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