TapRooT® Changing the Way the World Solves Problems

While TapRooT® occasionally utilizes discipline as a corrective action that must mean it is sometimes effective, right? But if you think about it, most people don’t do things wrong just for the heck of it unless somewhere they think it’s probably okay. They saw their co-worker take a shortcut just the other day and their manager told him “job well done” for getting the task done so quickly. Time is money, right! Time is money when things go right and when they go wrong. So, this time you took the same shortcut as you’ve seen others do, but this time something went wrong and now they have had to shut things down (at a minimum). Downtime is money too. You knew it was a shortcut, you knew you skipped a step in the procedure, but so does everyone else. What should the company do with you now that something bad happened?

If your company is great at enforcing its policies, you know if you take a certain shortcut to get done quicker than something negative will happen to you. There will be a consequence for not following the procedure and your company always enforces it. If that’s your company, then you are likely to think twice before taking that shortcut.

However, if you are at a company where people feel it’s okay to take shortcuts to get things done quicker (hoping all will be well and nothing bad will occur by taking that shortcut), it gets easier and easier within that company’s culture to take some shortcuts to get the job done. Because other people do the same shortcut and they sometimes get a pat on the back! But this time something bad occurred. Are you at fault for taking a known shortcut and then need to be disciplined? Not necessarily.

This topic is near and dear to Marcus Miller’s heart. Listen in as he discusses how enforcing boundaries and policies along the way consistently can help deter people from taking the wrong actions to begin with. Then if a shortcut is taken by an employee when there is a known constant, negative response to that action, perhaps then, discipline might fit. Even then when we dig deep enough, we can probably still find a deeper cause. Taking the time to investigate properly to get to the real root causes of why an incident happened is worth it! We can teach you how to do just that!

For more information on TapRooT® training: www.taproot.com/courses 

For information on our upcoming Global TapRooT® Summit: www.taproot.com/summit

1. Do a SnapChart®. 

     a. Is a visual timeline of what happened. Provides a clear picture of what happened and clarification of the incident so we can identify all the areas of potential improvement 

     b. Can be used as planning and data collection tool 

     c. SnapChart® is very simple to do 

     d. Early versions will be very simple, assumptions and missing info, fill that info in with (3 P &R), interview techniques. Spend time here to move through the analyzation phase efficiently 

     e. If you have not been to a 5 day consider our Webinar on improving Interview and Evidence collection techniques 

     f. Have conditions detailing the events. A s/c with 0 conditions is an indication of incomplete. Answers to our dictionary questions like to live in the conditions. “What do we know about each event?” 

     g. Remove blame focus in our SnapChart® 

     h. Why? 

     i. How? 

     j. Use on action and 1 verb per event avoid “and” 

     k. Use active voice opposed to passive voice to provide clarity 

     l. Ex “Pump 2B stop button is pushed by Operator A vs Operator A pushes 2B stop button 

    m. Be specific and precise 

     n. Quantify – instead of “hot” temperature was 100 F 

     o. Be neutral and objective 

     p. Do not use judgmental statements Don’t know how to create a SnapChart® . . . we can teach you! 

Contact us for onsite training at [email protected] or view our Public Courses at www.TapRooT.com/courses 

Already trained in TapRooT®, here is a link to our Software Academy for how to start your SnapCharT®: https://www.taproot.com/how-to-create-a-new-snapchart-in-taproot-vi/ 

To find out more about Interviewing and Evidence Collection, please see: https://store.taproot.com/search?q=Effective+Interview Contact us at [email protected] for more information!

We don’t find it surprising that you find 5-Whys root cause analysis lacking. The lack of effectiveness of 5-Whys RCA has been shown in simple investigations and major investigation. Even smart, well-trained users (Like Taiichi Ohno, himself) frequently jump to conclusions, follow a single root cause trail, and fail to adequately analyze the causes of human error. That’s why we find it so surprising that people still recommend 5-Whys root cause analysis because it is “easy.” Easy but wrong is the wrong answer when you are counting on your root cause analysis to save lives, stop injuries, improve equipment reliability, or stop quality issues. And there are other techniques that are easy but effective. Let’s look at one of the most famous 5-Why examples used by Taiichi Ohno), who created the 5-Why root cause analysis technique. He is quoted using the following 5-Why example to teach 5-Whys to others. Here is an example: 1. “WHY did the robot stop?” The circuit has overloaded, causing a fuse to blow. 2. “WHY is the circuit overloaded?” There was insufficient lubrication on the bearings, so they locked up. 3. “WHY was there insufficient lubrication on the bearings?” The oil pump on the robot is not circulating sufficient oil. 4. “WHY is the pump not circulating sufficient oil?” The pump intake is clogged with metal shavings. 5. “WHY is the intake clogged with metal shavings?” Because there is no filter on the pump. That’s it. The fifth WHY.  Taiichi Ohno says the “Root Cause” is:  “NO FILTER ON THE PUMP” Would you call that a root cause? I wouldn’t. What would the corrective action be? Probably to install a filter on the pump. What is wrong with this root cause analysis? To find out, we would have to dig deeper into the failed robot’s root causes. In our video, we will look at the three main problems with 5-Why root cause analysis and see how another technique, TapRooT® Root Cause Analysis, might produce a more thorough root cause analysis. 

Blog article on 5 Why: https://www.taproot.com/dissatisfied-...

 Links can be: Sign up for TapRooT® Training: 

https://www.taproot.com/courses

 Attend the 2021 Global TapRooT® Summit:  

https://www.taproot.com/summit/

Does your management may want fewer human errors? If

human performance at your facility lags behind what your management thinks is acceptable, you may

need to improve human performance. But how do you improve human performance? With a human

performance improvement program!

Mark developed his first human performance improvement program back in 1985. It’s an interesting story

of how I came to do that, but that story is for another time. The point of this post is to discuss how YOU

can develop your company’s human performance improvement program.

What Do YOU Need To Know About Human Performance Improvement?

Before you start developing a human performance improvement program, you should probably know

something about human error. There is a whole field of study about this called human factors or

ergonomics.

When Mark started designing his first human performance improvement program, he had just finished his

Master’s Degree with an emphasis on Human Factors. Also he had just left the Nuclear Navy with

extensive experience in high-reliability operations. Therefore, he had a pretty good background to

develop a program.

You probably don’t have time to get a Human Factors Master’s Degree or spend seven years in the

Nuclear Navy to get a background to develop a human performance improvement program. What should

you do? We would recommend:

1. Get as much information as you can about human factors.

2. Review other human error reduction/human performance improvement programs.

3. Review the large variety of human error reduction techniques being taught to understand how they

work and their human factors basis.

4. Get feedback or test how the various human performance improvement tools work.

That’s a pretty good list. We can help!

Learn more about the Stopping Human Error Book! https://www.taproot.com/stopping-human-error-

book/ and then buy the book: https://store.taproot.com/book-10-taproot-stopping-human-error

Sign up for the 2 Day Stopping Human Error Course: https://www.taproot.com/course/stopping-

human-error-course/

Join us at our 2021 Global TapRooT® Summit where you’ll learn more about this and many

other improvement program topics: https://www.taproot.com/summit/

They discuss what EHS professionals find challenging or frustrating about investigations.  Such as, many investigations never get to the “real root causes” due to bias, leading to actions that only address superficial issues or focus too much on behavior.Also, organizations rely on RCA tools that are too simplistic for the complexity we often encounter.  There is amazing value at integrating our technology that further visualize data/insights to help detect precursors before they could lead to more serious events.

We are pleased to announce our new partnership with Cority, a trusted EHSQ software solutions provider. With 30+ years of innovation and experience, Cority’s team of 500 experts serve more than 1200 clients across 30 industries in 100 countries, supporting millions of end-users. TapRooT® Investigators and Cority’s clients now have the opportunity to navigate seamlessly between the two solutions during an incident investigation process.

For more information on TapRooT® go to www.taproot.com

For more information on Cority go to www.cority.com

For more information on our partnership go to https://www.taproot.com/taproot-welcomes-our-new-partner-cority/

We’ve all seen accidents that involved automation. Probably the most dramatic case lately was the 737 Max crashes. 

We’ve probably also heard someone say that automation is more reliable than human control. In fact, there are systems that are so unstable that human can’t control the system without the help of automation (for example the B-2 Bomber).

So what is the right role for automation and the right role for the human? 

How can assigning the wrong role to the human or automation cause an accident?

That’s something that Mark Paradies studied while getting his Masters Degree. 

And the proper role of automation and the human (function allocation) is what we will discuss in this video.

So click on play and see how this video might help you when evaluating new systems (or old ones) at your facility,

Here are links to get even more information from our previous blog posts and a link to Mark’s thesis:

Automation and Human Error   https://www.taproot.com/automation-and-human-error/

Automation and Accidents  https://www.taproot.com/automation-and-accidents/

A Cognitive Allocation to Improve Nuclear Power Plant Performance  https://www.ideals.illinois.edu/bitstream/handle/2142/96486/Paradies_Mark_W_MS.pdf?sequence=1&isAllowed=y

Monday Accident & Lessons Learned: Is Automation the Solution to Human Error?  https://www.taproot.com/is-automation-the-solution-to-human-error/

Monday Accidents & Lessons Learned: When Automation Fails Without a Heads-Up   https://www.taproot.com/monday-accidents-lessons-learned-when-automation-fails-without-a-heads-up/

Monday Accident & Lessons Learned: How Can Automation Get You Into Trouble?   https://www.taproot.com/monday-accident-lessons-learned-how-can-automation-get-you-into-trouble/