TapRooT

Changing the Way the World Solves Problems

TapRooT Presentation

HUMAN E NGINEERING
Pa g es 93 -1 1 2

Hu m a n - M a c h in e
Inte rfa c e
l ab e ls NI

W o rk
En v iro nm en t

Co m p le x
Sy s tem
k n owl ed ge -

arran ge m e n t/
pl a c e m en t

ho us e k ee p i ng
NI
ho t/c o ld

di s pl ay s NI

we t/s l i c k

c o ntrol s NI
m o ni tori ng
al e rtn es s NI

li g hts NI

m o ni tori ng t oo
m a ny i tem s

pl a nt/un it
di ffere nc e s

ob s tru c tio n

ex c e s s i v e
li fti ng

eq ui p m en t gu ard NI

ba s e d d ec is i o n
re q ui red

No n -Fau l t
Tol era nt Sy s te m
e rro rs n ot
d ete c ta bl e
e rro rs n ot
rec o v e rab l e

no i s y

c ra m p ed qu arters
hi g h rad ia ti on /c o nta m i na ti on

to o ls /in s tru m e nts NI

SMARTER Corrective Actions

Revision 0, 7/00

Root Cause Definition

The most basic cause (or causes) that can reasonably be

identified that management has control to fix and, when
fixed, will prevent (or significantly reduce the likelihood
or consequences of) the problem's recurrence.

Fixing Root Causes to Improve Performance

Problems alert us to the need for improvement.
We could try to "change anything/everything" but it's
more effective to pinpoint fixes.
For most problems we can identify changes that will
enhance performance and eliminate the problem.
You need a reliable, systematic process to find fixable
root causes.

Choosing the Right Investigation Program

Must satisfy JCAHO requirements
Must identify true, fixable root causes consistently
Must be credible with the work force and encourage their active
participation in the investigation and review process
Must not overextend our ability to investigate and follow-up on
incidents
Must allow collection, comparison, and measurement of root causes
to provide meaningful trends
Must have consistency of results to facilitate the sharing throughout
organization of lessons learned to prevent recurrence

TapRooT
Use technique called SnapCharT
To understand what happened and how it
happened.
Use TapRooT Root Cause Tree
To use systematic process to find each
problem's root causes.
SMARTER Corrective Actions and Corrective
Actions Helper
To develop effective fixes

Diagram of TapRooT Process

Review Event
Report

Read through NCPS

Triage Cards

Determine
Sequence of
Events
(SnapCharT)

Define
Causal Factors

Analyze Each
Causal Factor's
Root Causes
(Root Cause
Tree)

Analyze Each
Root Caus's
Generic Cause
(Root Cause
Tree)

Develop &
Evaluate
Corrective
Actions
(SMARTER)

Report and
Implement Corrective
Actions
(DoD RCA Form)

SnapCharT
Condemnationwithoutinvestigationistheheightofignorance.
AlbertEinstein

SnapCharT Allows You To:

Have a thorough Understanding of What Happened
Spot missing or conflicting information
Keep focused on the incident (maintain objectivity)

SnapCharT Simple Example

Events
Who did what?
What equipment
did what?

Person walks
to car

Car in usual spot

in company lot

Incident

Reason for the Root Cause Analysis

Person
sprains
ankle

Person steps
in pothole

Hole not visible

after dark

Parking lot
light out

Light failed 3 days

ago - not reported

Transported
to hospital
& treated

Condition or Causal Factor

Amplifying information.
Explains event.

No barricades
around hole

Pothole reported
4 weeks ago no action taken

TapRooT Root Cause Tree

Chanceisawordwithoutsense;nothingcanexistwithoutcause.
Voltaire

TapRooT Root Cause Tree Allows You To:

Determine why people make mistakes
Determine why equipment fails
Understand the system causes behind incidents

TapRooT Root Cause Tree

15 questions to help team isolate causes for human performance
problems AND
A Tree of incident causes

Used to:
Systematically guide team to the root causes of human
performance & equipment problems
Focus on finding fixable causes rather than on placing blame
Provide common language for discussions & trending

TapRooT Root Cause Example

PROCEDURES
Pages 36-52

Not Used /
Not Followed
no procedure
procedure
not av ailable or
inconv enient
f or use
procedure
dif f icult to use
procedure use
not required
but should be

Wrong
ty po
sequence wrong
f acts wrong
situation not
cov ered
wrong rev ision
used
second checker
needed

TapRooT Root Cause

Followed Incorrectly
f ormat conf using
> 1 action / step
excess ref erences
mult unit ref erences
limits NI
details NI
data/computations
wrong or incomplete
graphics NI
no checkof f
checkof f misused
misused second check
ambiguous instructions
equip identif ication NI

TapRooT Generic Cause

A systems issue/problem that allows a root
cause to exist
Fixing the generic cause eliminates whole
classes of specific root causes

Develop SnapCharT
Get Started
- Determine what you are investigating
Define sequence of events
- Identify missing or needed
information
- Investigate further to find missing
information
Define causal factors

Root Cause Analysis

Analyze each Causal Factors Root
Causes
- Analyze one Causal Factor at a
time
- Begin at the top of the Tree and work
through the questions to determine
what Basic Cause Categories apply
- Examine all of the Basic Cause
Categories that apply to determine
what root causes apply
Use the TapRooT Root Cause Tree
Dictionary for definitions to all of the
questions and root causes on the Root
Cause Tree

Copyright 2000 by System Improvements Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.

Corrective Actions
S pecific
M easurable
A ccountable person
R easonable
T imely
E ffectiveness review
R eview for unintended consequences

Corrective Action Implementation

On-Site

START
HERE

Off-Site

Share with Other

Facilities

Incident

Other
Facilities
Evaluate & Decide
on Implementation
Immediate Fixes

No

Document
Decision

Document
Yes
Document/
Track/
Validate

Re-Analyze &
Develop New
Corrective
Actions

Implement Fixes

Investigation

Measure
Effectiveness

Long Term
Corrective
Actions
Recommended

TEST

Effective

Done
Re-Analyze &
Develop New
Corrective
Actions

Fixes
Implemented

Doesn't Work
TEST

Document/
Track/
Validate

Measure
Effectiveness

Effective

Doesn't
Work

QUESTIONS?

HUMAN ENGINEE RING

Pa ge s 9 3 -11 2

Hu m an - M a c hi n e
In te rfac e
la b e l s NI

W ork
En v i ron m e n t

Co m pl e x
Sy s tem

ho u s ek ee p i n g
NI
ho t/c ol d

k no wl ed g e-

a rra ng e m e n t/
p l a c e m en t
d i s pl a y s NI

we t/s l i c k

c o n tro l s NI
m o ni to rin g
a l e rtn e s s NI

li g h ts NI

m on i tori n g to o
m an y i te m s

p l a nt/u ni t
d i ffere n c e s

ob s truc tio n

e x c es s iv e
l i fti ng

eq u i pm en t g u a rd NI

to o l s /i n s tru m e n ts NI

b as e d d e c i s i o n
re qu i red

no i s y

c ra m pe d q u a rte rs
hi g h ra d ia ti o n /c on ta m i n a ti o n

Non -Fa u l t
To l e ra n t Sy s tem
e rro rs n ot
d e tec ta bl e
e rro rs n ot
re c ov e rab l e