November 18, 2009 | Dave Janney

Root Cause Analysis Tips – Work Direction

Happy Wednesday, and welcome to this week’s root cause analysis tips column.

This week I thought I would cover one of the basic cause categories – Work Direction. Work Direction speaks to who is in charge, and includes job preparation and supervision (selection of worker and supervision during work). The first notation in the dictionary under this basic cause category tells you to identify the “supervisor, team leader, or person in charge of the work.”

Let’s talk about preparation. First, let me ask a question; who is responsible for preparation, the worker or supervision? This is a trick question; the answer is “it depends” or “both.” I’m glad I could clear that up! But seriously, it does depend on your environment, the task being completed, and the associated risk. Workers are responsible for preparation and supervision is responsible for making sure preparation is adequate, so everyone involved has a piece of the pie; however, I am not one of these people who believes that everyone has to be supervised constantly, these folks are adults! You can be in charge of yourself (I hope) regardless of titles!

The first root cause listed under preparation is “no preparation.” That one is fairly straightforward – regardless of the type of preparation required, if it was not done this is what you would select. If preparation was done but did not work the way it should, then you would continue down to some of the other root causes under preparation.

For the root causes “work package/permit NI,” “pre-job briefing NI,” and “walk-thru NI,” you must consider whether those processes are used in your environment. If they are and they do in fact NI based on the facts in your investigation, then select them. If these are not part of your processes, you can consider selecting/adding them, but I would be very cautious because they are very broad in scope and will apply to many other processes. The best option is to select the root causes during step 4 and then consider whether you want to go that route during the corrective action phase of your work. I believe you should consider the risk before deciding to launch a new process like this; for example, if a mistake was made during a low risk process and your company does not use work permits, would you implement permits even though it might help? What other processes need permits? Be careful.

“Selection of worker” is also fairly straightforward; do you have the right trained people for the work and are they in the right condition to perform the work? “Supervision during work” is a little trickier, because again, we cannot supervise every one all the time or we have in effect added cost (and many times unnecessary cost). Risk has to be considered. If you have selected the proper worker/team and the task is low risk then you do not need someone looking over their shoulder. It is very easy to say they would not have made a mistake if the supervisor was there, but it is not that easy. Don’t make supervision a convenient scapegoat. Make sure you have the right processes in place and supervision should be less of an issue.

And……..don’t forget to read the dictionary!

Thanks for visiting the blog, and see you soon. Happy investigating.

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