April 21, 2021 | Mark Paradies

What You Don’t Know Can Hurt You (and your company)

Lack of Knowledge

How Does What You Don’t Know Hurt You?

What happens when you investigate a precursor incident and don’t find the real root causes?

You probably develop ineffective corrective actions.

What happens if your corrective actions don’t prevent the recurrence of a precursor incident?

The incident probably happens again.

Safeguard

And what happens if the next time the incident is slightly different and the last Safeguard (perhaps it was luck) fails?

Instead on a precursor incident, you have a major accident.

And what happens to you and your company when you have a major accident?

I can’t think of anything good.

What does this have to do with what you don’t know hurting you?

Read on and find out!

The Drawback of Cause and Effect

Many people use systems based on Cause and Effect to perform root cause analysis (5-Whys, Cause Tree, and Fault Trees to name a few). These systems have the investigator develop a cause and effect chain using their knowledge of the causes and effects of a particular type of failure.

5-Whys

This building of a cause and effect chain works OK if:

  1. The investigator knows all the potential causes of a particular effect.
  2. The investigator doesn’t have a bias toward a particular cause and effect chain (favorite cause-itis).
  3. The incident only has one cause and effect chain (or they will miss other potential root causes).
  4. The investigator knows when to stop (when they have reached the root cause(s).

In this case, we will only look at one of these drawbacks:

The investigator knows all the potential causes of a particular effect.

How many of your investigators know a majority of the causes of a particular incident? Few? None? This is especially true when the incident is related to a human error.

And what are the causes of most of your incidents? Human errors.

So, most of your investigators don’t know all the causes of the effects they are trying to investigate (human errors).

What can you do to solve this problem? Read on…

Expert System to Analyze Human Errors

Wouldn’t it be nice to have an expert system to help your investigators ask the right questions to understand the causes of human errors and develop effective fixes to stop repeat incidents?

Wouldn’t it be nice if a human factors expert:

  • Developed that expert system.
  • Had ten other human factors experts review the system and add their ideas and knowledge.
  • Tested the system with hundreds of users in several different industries resulting in improvements in the system and the training for the system.
  • Developed software to make the system easy to use.
  • Created an advisory board of users to continually test new ideas and recommend improvements over multiple decades.
  • Received feedback from thousands of additional users to improve the system, the training, and the software.

Yes, that would be nice … and it has happened. The TapRooT® System is a product of that development cycle.

Root Cause Tree® Diagram

Mark Paradies is the human factors expert (Certified Professional Ergonomist #85) who originally developed the system (and still works to improve it today).

Mark Paradies and Linda Unger had other human factors and equipment reliability experts review the system and then tested it with focus groups from the nuclear industry, the refining industry, the telecommunications industry, and the healthcare industry.

System Improvements (the company that brings you the TapRooT® System) started software development back in 1992, received a patent for the unique design, and is now on the TapRooT® Software version 6.9 – a cloud-based software that makes the TapRooT® System easy to use.

System Improvements created a TapRooT® Advisory Board to review improvements and suggest ideas to make the TapRooT® System even better.

System Improvements has trained and received feedback from hundreds of thousands of users from around the world.

That’s why the TapRooT® System helps investigators find the real, fixable root causes of incident and accidents and stops incidents from happening over and over again.

Time to Learn More About TapRooT® Root Cause Analysis

First, you can learn more about the history of the TapRooT® System at THIS LINK.

Hear Alex Paradies talk about TapRooT®’s development and the success using it at companies around the world.

And see the many TapRooT® User Success Stories at THIS LINK.

Next, see the variety of courses we offer to improve your root cause analysis at THIS LINK.

Then review our schedule of upcoming in-person and virtual root cause analysis training being held around the world at THIS LINK.

That should convince you to try TapRooT® and compare it to what you do today. We know you we find it superior because we have had so many people tell us that it is much better than the systems they used in the past (including many based on cause and effect).

Categories
Courses & Training, Human Performance, Root Cause Analysis
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