April 22, 2009 | Dave Janney

Root Cause Analysis Tips

Happy Wednesday and welcome to this week’s Root Cause Analysis Tips column.

I want to talk about procedures! 

Here is my disclaimer; procedures are valuable and absolutely needed in many circumstances.  However, I think careful consideration needs to be given to application and scope. 

We get into some interesting discussions during TapRooT® courses.   Every once in a while I get a student (or groups of students!) who want a procedure for everything.  Remember, a procedure in TapRooT® is actively referred to while performing the work (i.e. checklist).  You must be careful.

The TapRooT® Root Cause Tree® Dictionary asks the question “would performance improve if a well-written procedure was used correctly?”  You must make that call based on the severity of the incident, the task (and risk of the task) being performed, your company’s processes, and a dose of common sense.  I know – if sense was common, everyone would have it! But I digress………

I use this example; if I am doing a fairly routine task (like performing an oil change on a car) then it is not likely I need a procedure – I should be trained to do the job correctly, and then I should be able to perform the work.  However, if the task involves a great deal of risk (like starting a nuclear reactor), even if it is easy and I have done it many times before, it may be appropriate to require a procedure.  If a task is low-risk but difficult and has many steps, a procedure also may be appropriate. 

You must also consider whether a procedure can actually be used under the circumstances.  Remember, you are actively referring to the procedure while doing the work.  In our 5-day course we have a seatbelt example; a worker is injured when he is involved in an accident and is not wearing his seatbelt (required by company policy and law).  Many people want to require a procedure to prevent recurrence, but let me ask you a question – how is the guy going to read a procedure while he is driving?  Should we just give him a procedure to check off before he starts driving?  Overkill in my opinion – don’t make a procedure issue when one does not exist.  Management can enforce and communicate policies as well as procedures. 

If you require a procedure for mundane tasks that can be performed without one, you will get non-compliance (pencil whipping).  Or, you will get compliance and slow production.  Both are counter productive, and will not improve performance. Don’t make extra work for your employees for no reason.

We all have our favorite causes and corrective actions.  I’m a management systems guy, some people are training people, and some people are procedure people.  Don’t let your biases drive your analysis and corrective actions.  Be careful.

It is no accident that the TapRooT® Spin-A-Cause® tells you to make the procedure longer when you’ve determined procedures to be an issue.  Don’t do it!
If you don’t agree, I accept that.  You can buy the Spin-A-Cause® here (he he):  http://www.taproot.com/store.php

See you at a course soon; here is the schedule:


Happy Investigating!

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