Seven Secrets of Root Cause Analysis

everyone loves to hear a good secret right well we've got seven for you today and alex paradise is here with me and we're gonna we've got kind of a special treat you are going to provide our seven secrets root cause analysis webinar for everyone yep and let's just get started yeah let's jump into it hi everyone welcome to the seven secrets of root cause analysis webinar by taproot i'm alex paradise i'm going to be walking you through this webinar today just a note there is going to be some information that is shared in this that is protected by u.s copyright laws so do not distribute or repurpose anything you see in this presentation without express permission from system improvements in taproot if you want to get copies of this presentation or have this webinar done for your facilities go ahead you can reach out and contact me at alex paradise taproot.com or alex at taproot or you can go ahead and message info at taproot you can get some information on this webinar so just email info taproot.com if you want to get your own copy of this webinar or have this webinar performed for your team or people a little bit of a background on system improvements those who don't know we've been leading root cause analysis investigators and teaching tap root techniques for over 30 years our system was developed back in the 80s and really when we set out when our founders set out to create the taproot system they were really looking at the state of root cause analysis at that time and realized people weren't applying the human performance best practices and expertises that existed so our our fundamental mission became changing the way the world solves problems and you know providing people with the information and tools in order to do a really thorough investigation and what we're going to be talking about today are seven of the secrets that we've learned over those 30 years for how to perform exceptional investigations and how to dive down in incident investigations and fine root cause so we're going to be covering these seven secrets of root cause analysis and we're going to start right off the bat with secret with secret one your root cause analysis is only as good as the info you collect essentially garbage in equals garbage out if you're not collecting the right kinds of information and you're not organizing information correctly and you're not getting and digging in and getting the right information you're not going to have a good investigation so now you can see in this uh short little video we showed you here uh a person had a car accident they were falling asleep at the wheel they fell asleep drifted off the road and crashed the vehicle now a question you might want to ask is what kinds of information would you expect to get in an investigation like this if we did not have a dash cam and you interviewed this person and what kinds of things would they tell you would you hear that there was something in the road that i had to dodge it and i fell off the road did you would you hear that there was some extensive circumstance that you couldn't hear didn't know about if you didn't have that objective evidence on the dash cam looking at this person's face watching them fall asleep as they went off the road do you think you'd be able to get the information necessary to understand the mistakes that were made in an incident and that's something that's really critical and that's why we say though you know the first thing is you've got to get your facts straight and you've got to get the right information and and gather the right evidence and this is why things like video recordings and objective evidence are extremely important um in investigations secret number two you must understand what happened before you can understand why it happened now in taproot we focus on the what first in our planning and investigation phase we call we we start by gathering the information understanding where we need to investigate planning out who do we need to speak to where do we need to go and building out our snapchat which is a timeline of events before we start answering why before we start identifying those mistakes errors and failures before we start getting to root cause and developing corrective actions we really want to look for the what before we start asking why so here's another video example and i want you to focus on that red box you see those guys at that ladder at that red box that's what i want you guys to watch in this video here you'll notice the first man climbing up the ladder and you'll see a second man below that and he's holding some sort of blueprints in his hand and he begins to climb the ladder now when he's climbing the ladder you can see he's only using one hand to climb and he slips he lands on that second platform and he falls all the way to the ground and these two other gentlemen run over and they yank him up by his arms now if we pause this video right here and we looked around at the environment and we we kind of take a snapshot of what was going on you would notice that the guy was wearing he had a he had fall protection harness on but it wasn't clipped to anything in fact no one in the shot that's wearing fall protection is clipped to anything you'll also notice there's no mid-rail on that platform and you'll have noticed when he fell his arms were out in the fencing response there's some information we've we've got a lot of information we can go off of and determine from just from watching this video but you before you start answering why you need to understand the what and you need to organize the what and so this is where we teach the techniques for gathering information interviews physical evidence process data you've got to gather that information and you need to organize it because you know the last thing you really need in an investigation is paragraphs and paragraphs and paragraphs of information that it gives you details but it's impossible to decipher and read through so what we in tappery talk about is we talk about putting things in an easy to understand flowchart of information which we call the snap chart so this would be the snap chart of that scenario we just watched and from here you can see that timeline of events from the worker climbing the ladder reaching for that rung his hand missing the wrong falling from the ladder landing on the platform falling backward off that platform uh dropping approximately uh 14 feet to the ground and hitting the pavement so you can see that timeline of what happened and you can see the details that support under there things like the worker is only using one hand to climb worker does not have doesn't have any device to carry blueprints with him he's actually holding the blueprints in his hand he's not wearing any fall protection fall protection was provided but there's no policy for using fall protection when climbing a ladder there's only three points of contact required by company policy you might have information about there's no mid-rail that a mid-rail is required by osha requirements um and then that the person fell between the mid rail and the platform fell 14 feet you've got facts and information that helped describe that you might want to know about the workers training did they know what the fencing response looks like i think most of us in the safety industry understand when you see the fencing response the last thing you want to do is yank the guy up by his arms we all know that fencing response is an indication of potential for traumatic brain injury spinal damage things like that that person is in a concussed state we want to leave them on the ground and wait for medical to get there and evaluate the person before lifting them up and moving them because they could potentially have some damage and we could be making it worse by yanking the guy up so there's a lot of information that's that exists there and you have to organize this and understand it before you start identifying those mistakes errors and failures the person missing that rung and only using three uh one hand to climb they're not being a mid rail on the platform or the worker not wearing any fall protection there's different mistakes that occurred just like those guys lifting that worker up by their arms and you need to have a complete picture before you start selecting these things because if you if you start with the why you might just only focus in on the fact that he was climbing with one hand you might not think about well why didn't we have a mid rail why don't we require fall protection when climbing ladders why did these guys yank him up by the hands why do they yank him up after this injury we might miss these other opportunities for improvement and for bettering our system if we're not focusing on the why on the what before the y secret number three your lack of knowledge your knowledge or lack of it can get in the way of good root cause analysis obvious right if i don't have uh knowledge if i if i don't know things how on earth can i do root cause analysis well there's a lot of cause and effect assumptions that go into root cause and analysis there's a lot of techniques that are taught fault trees fishbone diagrams five why's all of these techniques are about organizing the what you know into different formats to help break down information you've got to know the cause and effect relationships to find out the root cause i've got to be an expert in the way things fail in order to understand what happened so your root cause analysis is limited by your current knowledge so when you're using these kind of cause and effect maps if you're not an expert you're never going to get down to root cause because you're not going to know the questions you need to ask in order to get down to root cause you're going to stay very surface level this leads to two kinds of traps the first is the inexperienced investigator trap you don't know all the potential causes you might only know one this came up with me a lot when when i was a manager i had brand new supervisors i had four supervisors of an area and out of those four supervisors only three of them had prior experience in that department they were experienced guys in different areas of the facility but they didn't have experience with my department and what i found is in their investigations when they were digging down to root cause they didn't ask enough questions they would stop at surface level things and not question enough they would take a lot of information at face value and didn't dig further because they didn't know what there was what things they needed to ask and what further areas they needed to investigate so they were only maybe finding one cause and they stopped they didn't dig more they didn't look at the whole process the second trap is the experienced investigator trap so your new people may not know the questions to ask and your experienced investigators may be biased may be biased to favorite causes and they might not have any psychology or human factors knowledge so you might have really experienced investigators that are really good at understanding the system failures but they don't understand the human factors side of it the human factors knowledge and human performance expertise knowledge in order to look at certain areas so an example of this you know if you've been in maintenance for 30 years and you find an incident that has some sort of failed equipment pump or failed you can you know i can go look at these maintenance logs i can decipher this information and go find where the mechanic or where the maintenance man wasn't doing what he needed to do in order to make this machine work the way it was supposed to but i may not be looking at different areas i may not have experience in training quality controls i don't know anything about procedure writing perhaps so you might have favorite causes i might know a lot about the the most effective ways to direct workers and give them effective brief job briefings and make sure they're prepared for their job but i may not know how to write a really good procedure i may not know how to um perform effective three-way communication so you may have very limited knowledge you might be an expert from years of experience in this process and be very strong on the process but you have very limited knowledge in this whole breadth of human factors or psychology that you might be missing so both of these traps lead to missed opportunities because you're not asking more the the in-depth questions necessary to dig deeper into problems so this is where tap roots a little bit different and what we kind of focus on so we focus on the what first then we get into the why and when we get into the why we're actually taking those mistakes errors and failures through the root cause tree and we're looking for missing best practices now there are seven basic cause categories in taproot there's training procedures quality controls communications management systems human engineering and work direction and just one of these categories i'm showing you here is human engineering and from this category we're looking for things that you can fix in our system we're looking for root causes as things you can fix things like labels that need improvement arrangement placement of materials were the people monitoring too many items was there an issue with the work environment so we have all these different criteria that we help guide you through the process of investigating and finding because our goal when we define root cause analysis it's the absence of a best practice or the failure to apply knowledge that would have prevented the problem or significantly reduced the likelihood or consequences so by searching for those missing best practices the goal of root cause analysis becomes finding the things we can implement to improve our system and prevent reoccurrence it gets you away from the blame game it gets you away from simple cause and effect and and focus more on how do you improve human performance so we do this in taproot by asking simple yes or no questions and we've got a lot of them that help guide investigators there's 15 questions that help you get into the categories and there's questions that help guide you down to specific root causes and some of these questions are pretty obvious this is one of our root causes here labels need improvements and the first question is pretty obvious you know are labels or warning signs missing that's a pretty obvious thing if we didn't have a warning sign or a label and somebody's pushed the wrong button that caused an incident you know a simple thing is to provide a label so that they know what they are supposed to push and what they're not supposed to if somebody exited out the wrong door and ended up getting injured because that door they thought it was an emergency exit and it was really a confined space entry and it wasn't properly labeled and there they entered in and got into a problem you know those things make a difference so if you don't have a label you should have one but we get a little bit more specific um what a better label or warning sign perhaps there this sign wasn't you had a sign it was really small and you couldn't see it perhaps that was hard to read maybe there was dirt smeared and things that that obstructed the label or perhaps it was unclear and ambiguous we had a scenario in my facility where we had uh maintenance had put him in a filter in one of our machines and we noticed after about a few days that we were having quality problems out of that machine and when we went back and we're plotting out and trying to troubleshoot and figure out what happened we looked back at the maintenance and we said you know we went through this maintenance what did you guys change out well we changed this filter well let's go look at what filter you put in there so we pull out the filter and indeed they put the wrong filter in and when we look to why they put the wrong filter and we went back and did some investigations what we found was there were two nearly identical filters they looked almost the same the boxes were the same same company the the names were almost the same the only difference between the two labels one of them is a 14 digit number and in the very middle of it was a b and the other one in the very middle of it was a d and the the maintenance guy that went back to go get the filter he looked he just looked saw the the five at the end and grabbed that one and didn't see the difference between the two so you could see the the label itself contributed and led to the poor label led to the person making the mistake and so you want to look at those things and we want to guide people down to these so we help guide you through that process with an expert system and you might ask well where do we come up with these categories where do we come up with these root causes well every one of these root causes in the taproot process comes from decades of human factors experience and engineering experience every one of our root causes is backed by research it's backed by experience not just our experiences but our thousands of taproot users and our 60 company advisory boards we evaluate our system to see what we're missing what we need to adjust what questions need to be tweaked secret number four interviews are not about asking questions i know what you're thinking if they're not about asking questions what are they about well interviews should be about stimulating memories and collecting the best possible information it's not about how good of questions you ask it's about how much you can get the person to speak and how much information you can get them to tell you so one of the things we do in taproot is we teach some cognitive memory techniques the very first one is stop interrupting people it's the most simple thing when you're when you're gathering information and when you're interviewing somebody the most effective thing you can do is have them start at the beginning in their own words tell you what happened start to finish and don't interrupt them because when you interrupt somebody that's in the middle of telling you a story you are breaking their memory chain you're breaking that chain of events because when you're recalling things it's like you're walking down a path in your mind and when you're recalling things you're thinking back and you're looking back and you're walking that path and when somebody stops you in the middle and asks you a question might be a relevant question mind you but when they ask you the question you're stopped you're coming back to reality and you have to find where you were in your brain again in that pathway and so by interrupting people you're interrupting that flow of memory and that makes it where people have far less detail that they end up giving you so one of the best things you can do at the beginning is let them start at the beginning and go start to finish now we cover a lot more about this technique in our five-day training course and in our free webinar on we've got we've got a webinar that you can attend we also have a self-guided course that you can attend on interviewing an evidence collection and we cover a lot of that but the main thing is leaning on here stop interrupting people when you're gathering and interviewing people let them speak let them get to the end then you can ask some clarifying questions you can have them revisit some things but let them go start to finish without interruption secret number five you can't solve all human performance problems with discipline procedures and training now i know a lot of people any every course i've ever taught i ask people what are the most common and they always come up with discipline training and procedures again and again and again and we always start we always ask them you know if it didn't work the first time when we disciplined retrained and we wrote a longer procedure why do we think it's going to work this time these are the standard three they're inside the box they're the defaults that everybody goes to and so what we want to focus people on is not just not just doing the same three things again and again and again and expecting different results that's the definition of insanity we want to give a tool to break you out of those and dig deeper now the first things we teach and we teach this in the five-day course is smarter corrective actions now i'm sure you guys have all heard smart corrective actions uh we have we have two more that talk about making sure we're verifying or that it's effective and we're reviewing the process with management um we cover that technique in our five-day course a lot more we also cover the hierarchy of safeguards this this comes out of a lot of that prior stuff with swiss cheese analysis and old school control of processes but when you're thinking about a problem you need to do the most effective kinds of corrective actions and the most effective things you can do are remove and reduce the hazard and the least effective things you can do are things like discipline training and procedures because discipline training and procedures don't really prevent reoccurrence they're really just trying to make humans more reliable safeguards when in reality you need to be focusing on elimination of those hazards and if you can't eliminate those hazards how can you remove the target from being around those hazards and if you can't do that how do you guard the target how do you improve human performance through good human factor design how do you design a system that is less likely to fail given that people are working in it and if you can't do that how do you organize information and if you can't do that how do you train people to be aware of those problems and not make those mistakes secret number six how as often people can't even imagine effective corrective actions even if they find the root the pro often people can't imagine effective corrective actions even if they find the problems root cause so this is actually a case that did come up from one of our courses this was one of the early courses that was taught back in uh the 90s it was early five day um it was before we had the corrective action helper we had uh we were teaching in one of our examples you find a root cause of labels need improvement and then we work with the person on coming up with corrective actions and this is an actual corrective action proposed by a person so the actual corrective action proposed was to tell people to be careful when operating equipment that isn't labeled tell people to be equi to be careful when operating equipment that isn't labeled and and it was at that moment we realized you know people need help coming up with root with with corrective action sometimes you can find the problem you didn't have a label so you'd think the easy obvious solution add a label no we're going to tell people to be careful when operating things without a label no that's not that's not a good that's not a good corrective action so we realized we needed to provide some guidance so what we did for every single root cause for every single near root cause category basic cause category in the taproot system there is a corrective action helper guide section on that there's a whole section it looks at a check it gives you guidance on how to evaluate that that issue how to look for generic causes that might be allowing this issue to be a problem not just in this area but in other areas and there's also references and guides that to reference to others outside standards that you can reference to develop better corrective actions so it helps come up with both better short-term and long-term measures for effectiveness and we provide this in our software as well as a paper-based copy that you get when you come to tap your training and it's things like uh for labeling uh this is our this is our corrective action section for uh labels need improvement we talked about earlier we didn't have a label on something it always starts out with that most obvious you know ideas for improvement you should consider recommending improving labeling you'd think that's too obvious nobody needs that guidance and yet remember that previous example people need to think about this first improve the label but it gets better than that we talk about making things easy to recognize and see perhaps making it a different color that stands out from the background if i've got five pipes that i need to identify a different color helps me identify those pipes in that background it also again like i said looks for generic causes and provides references and standards if i need help on designing a better label maybe i want to go look at the nuclear engineering regulation 0-700 you know look at how in the nuclear industry how they build the most effective labels secret number seven all investigations do not need to be created equal but some investigation steps should never be skipped this is kind of a question that we always want you guys to think about is should every investigation be a major production do i need a cross-functional team on every investigation do i need to be reporting up all the way to the vp for every accident or is there some stuff that needs a a simplified methodology and i think the answer is obviously no not every investigation should be a big production so this is why in taproot we give you two different investigation options we have the seven step major investigation process for those higher risk major impact investigations and then we have the taproot essentials process which is our low to medium risk less complex process now they're still the same fundamentals you're understanding the what then you're understanding the why and you're coming up with corrective actions that's still going to exist in that lower that that essentials technique but we also have a nothing more to learn category because there are times when you're going to gather information and realize the likelihood of this occurring is so low and the consequences were so low it is not worth our resources time to spend and develop corrective actions for there is only so much time your investigators have in a week and a day in a year and your you really should be thinking about yes it's worth collecting evidence on a paper cut on a finger cut on a first aid incident it's worth collecting some details and getting some information on that but is it worth spending a trained investigators time to dig into things that have a very low consequence or low probability of reoccurrence if somebody's if somebody's walking in our park parking lot and is it's flat level there's nothing no cause for issue and they fall for what appears to be no reason other than perhaps they tripped on their shoe or something and they twist their ankle that's a pretty low thing that we've all you know it doesn't happen very often though we've all had probably something like that occur in a facility but is it really worth redesigning our entire parking lot for probably not um but it is worth collecting information and making sure that there's not something missing we want to make sure that we're not missing hey the parking lots have been out for six weeks and nobody's reported it nobody's fixed it or hey you know we had ice and we didn't follow our icing procedure where we didn't send we didn't salt the ground before the the heavy ice and freeze you know we want to make sure that we didn't make any of those kind of mistakes we want to gather that evidence but we don't want to spend time digging about root cause and digging at corrective actions when it's not necessary that's why in taproot we just focus on the essentials finding out your snap chart finding those mistakes errors and failures that led to the incident then taking those mistakes and finding the root cause taking them through to the corrective action helper and finding those innovative solutions to fix those root causes that's the essentials technique and we do that whether it's a low medium risk or the high risk but we want to really evaluate is this worth our investigators time to go further than just gathering the facts now this is the portion i kind of talk a little bit more about taproot if you haven't gathered from this taproot is really focused on understanding why people make mistakes and why humans why humans make the mistakes they do and how do you build a system that prevents people from making mistakes so you can apply our techniques in health and safety and environmental issues process safety quality issues customer complaints security it works anywhere that people are making mistakes in a system and you want to understand what you can be doing to prevent them from those mistakes from reoccurring taproot is a great way to apply that in those techniques um there's lots of things i could tell you about return on investment but i really want to tell you a story that that makes a lot of difference to us at taproot you know every year we have our taproot summit we we have them every year this year we're looking at doing a taproot summit in the summer there's potential for those things to be online as well to share this out with people but every year we do the summit we gather all the people we have a lot of people that have been trained our experts some of our instructors as well as some of our super users our clients that have been using taproot for a very long time and and want to learn more we all come together and we we work we converse and at that taproot summit there was really an interesting story that came up and it and it happened to our founder this was one of the first summits that that we did and he was presenting and at the end of the presentation he got down and he was walking through the crowd and one of the guys came up to him and he said you know mark i just wanted to shake your hand and i wanted to thank you on behalf of our company and really on behalf of every company that's here and i just want to say thank you and mark just kind of take it aback said okay you're welcome what what exactly for and he said well you know at my facility we don't have fatalities anymore and and mark's gonna take it back and tell me more and the guy said well you know we used to have one fatality about every 18 months at our facility and since we started using taproot and started applying it proactively we don't have fatalities anymore and we've been using taproot for about four years and the way i figure it is that's four people that have been able to go home to their families and and that's you know 16 or so people's lives that have been you know affected because their spouse came home or their brother came home or their son came home you know and we just wanted to thank you on behalf of our company for that and and the guy the guy went on to say you know looking around the room there's hundreds of companies here and and when i think about it there's hundreds of lives that have gone home to their families there's hundreds of husbands and wives and sons and daughters and brothers and sisters that are now back with their family that might not have been if these people weren't using taproot and i just wanted to thank you for that and that was one of the first moments that it kind of hit us at about the effect that we really have on a company it's not just dollars it's not about reducing lost time or workers comp claims it's not about increased reliability or regulatory turnaround all of those things are great for the company and they're great for those of you know our clients that implement those but at the end of the day for us the most important thing is that because of our technique and because of what we're teaching people and because of the way it's being applied in companies people are going home to their families and that makes the biggest difference to us and so that that's that's really what i want to share with you not about the way you can get roi but the effects of good root cause analysis is not about good roi but it's about people going home to their wife and kids and that's the most important thing to us and that's why we kind of consider a partnership with our clients we're not just trying to tell to sell training we're not just not just trying to sell a product we sell a partnership with our clients we work through a road map to success from understanding what are your clients needs what are our partners focused on achieving their organization who do we need to focus on how do we gain management acceptance how do we gain compliance how do we get the most value and how do we do that over the long haul we work with our clients to develop out a plan that goes from the beginning of a process of understanding needs all the way through to continuous improvement a decade down the road so that's kind of some other things and i want to give you a little bit of the taproot advantages you know again we're an expert system that provides a structured guidance for your investigators it's going to be based off of extensive human performance expertise which that means even your inexperienced investigators are going to be able to ask ask the same questions and get the same answers as a trained human performance expert this leads to consistent investigation results and trendable data because we have a categorized list you're going to be able to trend the information that you get from root cause analysis we also have a proven process that removes investigator bias we're forcing people to ask questions they've never asked before and look at areas that they've never looked at before and with that all of our investigators you know that use taproot get a comprehensive set of human performance expert investigator questions we're going to be looking at things like fatigue we're going to be looking at things like work direction communication styles training objectives human machine interfaces knowledge based systems this this really helps people look deeper into processes they may not be familiar with and finally once you know the root cause we're going to be helping you find innovative and better corrective actions using the corrective action helper and the hierarchy of safeguards and taproot is really good because you have these questions you have these human performance best practices which means not only is it a reactive tool for when accidents occur but it can be a proactive tool to help prevent reoccurrence and help prevent an accident before it happens we can audit and make sure our systems have the robust best practices that are out there we also offer software this integrates with intellects enable on qwerty there's others on the way because we have an open api that can connect with your systems and share information we also offer on-site implementation of software as well as connection to your active user directory we also have a taproot app you can go to itunes download that taproot app right now it's on apple i2 ios and android devices and you can use that to help gather information and connect it right into your software and information right out of the field into there we also provide report customization that fits your industry's needs whether you've got a report to government agencies you've got to report findings or maybe you guys have specific details of things you want to record and record our software is customizable and our reports are fully customizable as well as well as we offer built-in investigation grading and coaching modules as well as trending so you can track and trend your uh your incidents to make sure you're understanding what kinds of problems are propping up in what areas it is a cloud-based solution and we offer hosting where we'll host the data for you or you guys can host the data on your servers if you want more information about that you can reach out to me or at alex at taproot.com or you can reach out to info taproot so if you're looking to get an executive briefing or learn more maybe a software demo feel free to email myself or to go to info taproot.com for more information so with that i want to thank you guys for sticking through the whole presentation and uh i hope you like comment subscribe if you've got questions again feel free to reach out to me and we'll see you later at another taproot tv episode bye

Channel: TapRooT®

Views: 8,754

Keywords: Safety, Improvement, Software, Root Cause Analysis, Quality, Maintenance, Process, Proactive, Prevention, Corrective Action, System Processes, Causal Factor, 7 Secrets To A Successful TapRooT®, TapRooT®

Id: -3KacrTlZJg

Length: 37min 50sec (2270 seconds)

Published: Wed Feb 03 2021