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Posted by
Mark Paradies
Efficient root cause analysis should be what every company and industry strives for. Of course
you need effective root cause analysis, but why waste resources on root cause analysis if you
dont need to use them there? Thus you need efficient AND effective root cause analysis.
Of course all right-sizing, cutbacks, and efficiency initiatives have a dark side striving too
much for efficiency can lead to too little emphasis on quality. Thus companies need to make
sure that they dont devote too few resources to root cause analysis of problems. If companies
invest too little in root cause analysis, they will end up using even more resources by:
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Having recurring incidents and repeating investigations that werent done correctly in
the first place,
Wasting effort on corrective actions that only address the symptoms and not the real
root causes,
Wasting management effort reviewing investigations and root cause analysis that isnt
as good as it should be (and therefore gets rejected by management)
Being cited by a regulator for poor investigations and inadequate root cause analysis
Having a major fine or your facility shut down over a regulatory issue that could have
been corrected earlier by good root cause analysis
Having a major accident that could have been prevented by good root cause analysis
of the prior incidents that were warning you about a problem (If only you had listened
more effectively!).
So devoting enough resources to root cause analysis without going overboard is the key to an
effective, efficient performance improvement program that you can continually apply and
which will produce a healthy return of the effort and $$$ invested.
So what are the keys to efficient yet effective root cause analysis? Read on and see
When I think of efficient, effective investigations, I think of using TapRooT(R).
TapRooT(R) was designed and has been improved over the years to provide a tool that
produces effective root cause analysis and investigation EFFICIENTLY. But to be efficient and
effective you need to use TapRooT(R) the right way.
What is the right way to use TapRooT(R) efficiently and effectively? Here are my TOP 10
suggestions for using TapRooT(R) efficiently yet effectively:
1. Sufficient training and practice for the investigation facilitator (team leader) and the
investigations team.
2.
3.
4.
5.
6.
Assigning enough, but not too many, people to the investigation team.
Use investigation team efficiency strategies.
Get inside/outside help when needed.
Be prepared for an investigation BEFORE the incident/accident happens.
Dont waste time investigating small problems that dont deserve to be investigated.
Instead, use trending to spot developing problems from small issues and then apply
root cause analysis.
7. Keep up-to-date on current investigation best practices.
8. Use your TapRooT(R) Tools effectively to improve efficiency.
9. Get employees (not just team members) trained in the basics.
10. Get management trained.
Let me share a few more ideas about each idea so that you can apply these ideas and get the
most return on investment possible from your investigations and root cause analysis.
1. Training and practice for the investigation facilitator (team leader) and the
investigations team.
Lets talk about training first. Any professional knows that over training and practice helps a
team perform well when the pressure is on. Professionals at all levels (from the military to
professional sports to highly educated
The more serious the accident, the more the investigation team will be under pressure. Thus
the more training and practice they will need to assure good performance.
But even (or especially) for minor incidents, an untrained or poorly trained team can waste
considerable resources and make root cause analysis look like a waste of time.
Therefore, you must start thinking about OVER training your team leaders and team
members.
So lets start out with what the recommended training. Then we can review OVER training.
Recommended Training:
Team Leader: the 5-Day TapRooT(R) Advanced Root Cause Analysis Team Leader Training
Team Member: the 2-Day TapRooT(R) Incident Investigation and Root Cause Analysis Team
Leader Course
Team Member (equipment analysis): the 3-Day TapRooT(R)/Equifactor(R) Equipment
Troubleshooting and Root Cause Failure Analysis Course
If your teams are trained to this level, you are NOT OVER-TRAINING. This will result in
inefficiencies in your root cause analysis. Especially for inexperienced investigators. In other
words, your training is meeting the recommended requirements but investigators will need to
gain experience to become efficient.
Think of the recommended training as the minimum octane that will make your car work. It
will run but it will sputter, backfire, knock, and be very inefficient under heavy loads.
But training isnt all that is needed. To keep the skills sharp, investigators and team members
need practice and feedback.
They should perform no less than one investigation per month.
They should get feedback on this investigation (both positive and negative feedback) from the
sites EXPERTS in root cause analysis a peer review committee of three or four of the best
investigators.
The feedback should be aimed at:
-
Attend advanced root cause analysis, incident investigation, human performance, and
equipment troubleshooting training every year. These could include courses given before
the TapRooT(R) Summit like the Stopping Human Error Course, the Coaching Skills
Course, the How To Interview and Gather Information Course, the Creative Solutions
Course, the Advanced Trending Techniques Course, or the Equifactor(R) Course.
Provide a presentation to investigation team members at their site and management about
the lessons learned from the Summit and the advanced training that they attended.
Attend at least one other professional conference about improvement topics of interest.
Read each issue of the Root Cause Network(TM) Newsletter and the TapRooT(R)
Friends/Expert e-Newsletter and subscribe via RSS feed to the Root Cause Analysis Blog.
Attend advanced root cause analysis training at least every two years.
Provide a presentation to investigation team members at their site and management about
the lessons learned from the Summit and the advanced training that they attended.
Read each issue of the Root Cause Network(TM) Newsletter and the TapRooT(R)
Friends/Expert e-Newsletter and subscribe via RSS feed to the Root Cause Analysis Blog.
Attend the presentation by the key investigator about the Summit and the advanced
training.
Read each issue of the Root Cause Network(TM) Newsletter and the TapRooT(R)
Friends/Expert e-Newsletter and subscribe via RSS feed to the Root Cause Analysis Blog.
Attend the presentation by the key investigator about the Summit and the advanced
training.
A well trained (over-trained) team will make investigations look much easier and much more
efficient.
2. Assigning enough, but not too many, people to the investigation team.
a) Use the Spring SnapCharT(R) to plan the investigation . Planning reduces needless
effort.
b) Think about interviews and schedule them to efficiently collect information and to
minimize interviewers and interviewees time.
c) Use no more than two investigators in an interview.
d) Dont waste time doing things in team meetings that could be done by one individual
outside the team meeting (for example, redrawing a SnapCharT(R)).
e) Call a temporary halt to the investigation and let people get back to their normal jobs if
analyses or information is delayed/wont be available for a period of time.
f) Keep an investigation to-do list and a meeting to-do list to keep the investigation
and meeting on track.
g) Let the investigation team know that you, the team leader, and management are
interested in investigation efficiency and effectiveness. Then track the hours spent and
find out why things are taking longer than planned.
h) Make sure that their is sufficient management support for an investigation.
Investigators cooling their heals waiting for people to interview, fights with contracts
over support purchase orders, or the inability to get a meeting room to use as the war
room for the investigation team should not occur or should be solved by
management support. The main challenge in getting an investigation done should not
be overcoming bureaucratic obstacles. If these obstacles are slowing down
investigations, get them solved once-and-for-all.
i) Have administrative assistance available for the team. Copying and other
administrative tasks should be handled by the appropriate staff.
4. Get inside/outside help when needed.
And investigation team needs to know when to get help and their should be pre-planned
assistance available for:
-
metallurgical analysis
oil analysis
human factors analysis
outside expert facilitators
accident reconstruction
technical experts on equipment
computer experts
Once upon a time, companies had their own internal experts. Now, most of this expertise has
been downsized. Make sure that you have planned to get this expertise when you need it.
(Contracts already in place before an accident even happens.)
5. Be prepared for an investigation BEFORE the incident or accident happens.
Have you prepared for investigations? Read Appendix A of your TapRooT(R) Book and then get
things prepared.
public attending. The extreme consequences means that this will also be the most difficult
type of investigation. This type of investigation will take a dedicated team of highly trained
company investigators and consultants to conduct a thorough review of all evidence. The
complete suite of TapRooT(R) Techniques will be employed. A considerable investment in time
and resources will be required as well as senior management review or the investigation
results and potentially an independent review by a highly experienced outside reviewer. This is
obviously NOT they type of investigation imagined by this question.
b. Serious Incident: The level of damage or loss caused by this incident is worthy of
investigation and root cause analysis. This incident is serious because it cause damage just
below that required to trigger a Serious Accident investigation or because it could have
easily caused a Serious Accident with slightly different circumstances or without the
intervention of luck. This investigation will be similar to the investigation above with the
exception that some of the team members may be slightly less experienced, less consultants
will be used, and the review of the investigation will be by local management and an
investigation peer review committee made up of local investigation experts. Once again, this
investigation is above the minor investigation posed by the users question.
c. Incident: This incident caused minor damage or loss and there was at least one significant
safeguard (which was NOT luck) to keep the incident from becoming a Serious Incident. In this
case, a single investigator or a small investigative team may be used to perform the
investigation and only two tools will be used to perform the investigation: SnapCharT(R) and
the Root Cause Tree(R). These types of incident investigations will receive a brief review by
the peer review committee but will not receive management review unless a trend is
detected.
d. Recordable Event: These events are judged to NOT be worthy of investigations. The type
of event, organization, and the location are recorded in a database to allow trending. Since no
investigation is performed, no corrective actions are recommended and future recurrence of
the event is possible. Trends will be used to detect significantly increasing frequency of these
events.
Here is a tip for the nuclear industry: All significant conditions adverse to quality should
be rated as an incident or above and therefore deserve root cause analysis. If it is not a
significant condition adverse to quality and it is not in another category that makes it
significant (cost, delayed startup, personnel injury, non-nuclear environmental release, ),
then a nuclear facility should categorize the problem and NOT waste time doing some sort of
halfhearted Apparent Cause evaluation that will waste time and corrective action effort
implementing fixes that arent effective.
7. Keep up-to-date on current investigation best practices.
Every year the TapRooT(R) Summit presents new good practices for investigations. These have
included ways to improve investigation efficiency and effectiveness. Recently, the Summit has
a whole track devoted to investigation best practices. Examples from the Summit planned for
April of 2006 include:
-
If each year you implement best practices for your investigations, you will have an industry
leading investigation program that is efficient and effective!
8. Use your TapRooT(R) Tools effectively to improve efficiency.
The TapRooT(R) System was designed to promote effective, efficient investigations. The
TapRooT(R) Software was designed to make the TapRooT(R) System even more efficient.
How?
First, the software supports the investigator buy providing an easy-to-use tool for drawing
presentation quality SnapCharT(R)s.
Second, the software makes access to the Root Cause Tree(R) Dictionary a snap (just one click
away).
Third, the results of your investigation are recorded while the analysis is performed. No need
to enter data separately.
Fourth, the Corrective Action Helper(R) Module provide great ideas for developing corrective
actions. This adds greatly to the efficiency and effectiveness of the corrective action process.
Fifth, the Equifactor(R) Troubleshooting Tables can help investigators develop troubleshooting
plans so that key equipment failure evidence is not lost and troubleshooting is done in the
most efficient/effective manner.