taproot brief

TapRooT®

Changing the Way the World Solves Problems

TapRooT® Presentation

SMARTER Corrective ActionsRevision 0, 7/00

HUMAN ENGINEERING

labels NI

arrangemen t/plac emen t

dis play s NI

plant/uni tdi ffe renc es

Human - Mac hineIn te rfac e

mon ito ringale rtnes s NI

hous ek eepingNIho t/c old

l ights NI

no is y

equipment gua rd NI

W orkEnv i ronment

k nowledge-

bas ed dec is ionrequi red

Comp lex

Sy s tem

mon ito ring toomany i tems

e rro rs no tdetec tab le

e rro rs no trec ov e rable

Non-Fau l tTole ran t Sy s tem

c on tro ls NI

c ramped qua rters

we t/s l ic k

too ls /ins truments NI

ex c es s iv eli fti ng

obs truc tion

Pages 93-112

high rad ia tion /c on tamina tion

©Copyright 2000 by System Improvements Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.2

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.

Root Cause Definition


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

Read through NCPSTriage Cards

DetermineSequence of

Events(SnapCharT)

DefineCausal Factors

Analyze EachCausal Factor's

Root Causes(Root Cause

Tree)

Develop &Evaluate

CorrectiveActions

(SMARTER)

Report andImplement Corrective

Actions(DoD RCA Form)

Review EventReport

Analyze EachRoot Caus's

Generic Cause(Root Cause

Tree)


SnapCharT®

“Condemnation without investigation is the height of ignorance.” Albert Einstein

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

Person walks to car

Person steps in pothole

Transported to hospital & treated

Person sprains ankle

Car in usual spot in company lot

Pothole reported 4 weeks ago -

no action taken

Parking lot light out

No barricades around hole

Hole not visible after dark

Light failed 3 days ago - not reported

Incident Reason for the Root Cause Analysis

Events Who did what? What equipment did what?

Condition or Causal Factor Amplifying information. Explains event.


TapRooT® Root Cause Tree ®

Chance is a word without sense; nothing can exist without cause. 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

Not Used / Not Followed

PROCEDURES

procedure use not required but should be

no procedure

procedure not available or inconvenient for useprocedure difficult to use

typosequence wrong

facts wrong

situation not coveredwrong revision usedsecond checker needed

> 1 action / step

checkoff misused

Followed Incorrectly

format confusing

no checkoff

graphics NI

limits NI

excess references

details NI

Wrong

Pages 36-52

mult unit references

data/computations wrong or incomplete

equip identification NIambiguous instructionsmisused second check

TapRooT® Root Cause


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

13

Develop SnapC

harT®

Get Started

- Determ

ine what you are investigating

Define sequence of events

- Identify missing or needed

information

- Investigate further to find missing

information

Define causal factors

Root C

ause Analysis

Analyze each C

ausal Factor’s Root

Causes

- Analyze one C

ausal Factor at a tim

e- B

egin at the top of the Tree and work

through the questions to determine

what B

asic Cause C

ategories apply- Exam

ine all of the Basic C

ause C

ategories that apply to determine

what root causes apply

Use the TapR

ooT® R

oot Cause Tree

®

Dictionary for definitions to all of the

questions and root causes on the Root

Cause T

ree®

©C

opyright 2000 by System Im

provements Inc., K

noxville, TN. A

ll Rights R

eserved Worldw

ide. 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

Incident

Immediate Fixes

Long TermCorrective

ActionsRecommended

FixesImplemented

Re-Analyze &Develop New

CorrectiveActions

TEST

Share with OtherFacilities

Evaluate & Decideon Implementation

DocumentDecision

Implement Fixes

TEST

Done

Re-Analyze &Develop New

CorrectiveActions

Investigation

STARTHERE

On-Site

Document

OtherFacilities

No

Yes

Doesn'tWork

Effective

MeasureEffectiveness

Document/Track/

Validate

Document/Track/

Validate

MeasureEffectiveness

Effective

Doesn't Work

Off-Site


QUESTIONS?

HUMAN ENGINEERING

labe ls NI

arrangement/plac ement

dis p l ay s NI

plan t/un itdi f fe rences

Human - Mac h ineIn te rfac e

mon itori ngale rtnes s NI

hous ek eepi ngNIhot/c ol d

l i gh ts NI

noi s y

equ i pment guard NI

W orkEnv i ronment

knowledge-

bas ed dec i s i onrequ ired

Co mplex

Sys tem

mon i toring toomany i tems

erro rs notde tec table

erro rs notrec overab le

Non-Fa u ltTol e ra nt Sy s tem

controls NI

c ramped quarte rs

wet/s l ic k

too l s /i ns truments NI

ex c ess iv eli ft ing

obs truc tion

Pages 93-112

h igh rad ia tion /contamina ti on

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