Effective Incident Investigation with TapRooT
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1 Effective Incident Investigation with TapRooT Per Ohstrom, Vice President Pennsylvania Governor s Occupational Safety & Health Conference, October 2018 System Improvements, Inc. 238 South Peters Road, Suite 301 Knoxville, TN 37923, USA Phone: Blog: Copyright 2017 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited. Page 1
2 A Big Small Company Head office Knoxville, TN Trainers located in many countries and regions 30 year history from start in nuclear power 100,000+ professionals trained Copyright 2017 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited. Page 2
3 What can TapRooT do? Environment, Health and Safety- accidents, near-misses, environmental releases or human errors Quality issues Improve human performance Understand and reduce equipment related failures Improve effectiveness and impact of corrective actions Easy to Use Consistent results Systematic, Saves time and money Reduces Investigator bias Expert system Human Performance based Copyright 2017 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited. Page 3 3
4 TapRooT method flow 1. Understand what happened, collect data and draw a SnapChart visual timeline Anything more to learn? If so, continue! 5. Develop fixes with the Corrective Action Helper 2. Find out why a problem occurred - determine Causal Factors 4. Develop Root Causes using the Dictionary 3. Work through Root Cause Tree to find Basic Cause categories Copyright 2017 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited. Page 4
5 It only takes a second Copyright 2017 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited. Page 5 5
6 Start with a SnapCharT Visual timeline Plan, collect data Basis for rest of analysis Copyright 2017 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited. Page 6
7 Conditions What Happened? Events Incident Events Only proven facts and questions, NO opinions, judgments, names Copyright 2017 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited. Page 7
8 SnapCharT in software Who does what? Lack of action General information Undesired action Policy information Copyright 2017 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited. Page 8 8
9 Find Causal Factors mistake, error, or failure that directly leads to (or causes) an Incident, or fails to mitigate the consequences of the original error Indicated by triangle symbol Initiate/ Stop/ Catch/ Mitigate Copyright 2017 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited. Page 9 9
10 Analyze Causal Factors, find Root Causes The absence of a best practice or the failure to apply knowledge that would have prevented the problem Copyright 2017 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited. Page 10 10
11 Root Cause Tree Causal Factor Name Here Copyright 2017 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited. Page 11
12 Human Performance expert system 15 Questions relating to Causal Factor: - Cross off NO - Circle YES - Keep going Circles point to categories on back of page Copyright 2017 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited. Page 12
13 Basic Cause Categories Evaluate for Root Causes Other categories are eliminated Copyright 2017 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited. Page 13
14 Example: Finding root causes Copyright 2017 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited. Page 14
15 Develop fixes Corrective Action Helper : Suggestions References Copyright 2017 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited. Page 15 15
16 What are good Corrective Actions? STRONGEST WEAKEST 1. REMOVE / REDUCE THE HAZARD 2. REMOVE THE TARGET 3. GUARD THE TARGET 4. IMPROVE HUMAN PERFORMANCE with good Human Factors Design 5. IMPROVE HUMAN PERFORMANCE with Rules, Procedures, Signs 6. IMPROVE HUMAN PERFORMANCE with Training, Supervision, Discipline Copyright 2017 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited. Page 16
17 3 Secrets of Investigations 1. Your knowledge can get in the way of a good root cause analysis 2. Interviews are NOT about asking questions 3. Trending helps you get better Copyright 2017 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited. Page 17
18 1. Your knowledge can get in the way You must know cause and effect relationship to find the root causes Inexperienced Investigator Trap: Don t know all the potential causes (maybe only one!) Experienced Investigator Traps: No Psychology / Human Factors Knowledge Favorite-Cause-itis Copyright 2017 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited. Page 18
19 2. Interviews are NOT about asking questions Stimulate memories and collect best possible information Cognitive Interviewing Techniques Use the SnapChart Ask to explain in own words Ask how and what, not why Listen, don t interrupt Ask for ANY important info they can share Copyright 2017 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited. Page 19
20 3. Why Trend? Spot bigger, underlying issues Prove routine variation is NOT a trend See impact of improvement over time Copyright 2017 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited. Page 20
21 Why does TapRooT work? Other Methods Easier to use and do not limit thinking when looking for root causes Cause-and effect Fishbone analysis 5-Whys Software programs Timeline of events? Jump straight to root cause No support for corrective action development TapRooT Not depending on investigator expertise like deductive reasoning methods Less confirmation bias TapRooT provides structure for use by non- experts: Focus on human error Thorough information collection More than one root cause More efficient problem solving Consistent results enable trending over time Copyright 2017 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited. Page 21
22 TapRooT RCA offerings Public and On- site Training: 2-Day TapRooT Root Cause Analysis 5-Day TapRooT Advanced Root Cause Analysis Team Leader 3-Day TapRooT /Equifactor Equipment Troubleshooting and Root Cause Failure Analysis TapRooT VI Software Multi- User Corporate License Single user SaaS subscription Consulting Complex or high stakes investigations TapRooT implementation Copyright 2017 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited. Page 22
TapRooT VI Software Quick Start Guide
TapRooT VI Software Quick Start Guide TapRooT Technical Support: Monday Friday: 7am 6pm EST Phone: 011 (865) 357-0080 Email: support@taproot.com Copyright 2016 by System Improvements, Inc., Knoxville,
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