Get Your Root Cause Analysis PhD
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Transcript of Get Your Root Cause Analysis PhD
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2014 Global TapRooT® Summit
Horseshoe Bay, TX
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2014 Global TapRooT® Summit
Changing the Way the World Solves Problems
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Get Your RCA PhD!
Mark Paradies President, System Improvements
The TapRooT® Folks www.TapRooT.com
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Do You Know Everything There is To Know About Root Cause Analysis?
BS: 2-‐Day TapRooT® Course MS: 5-‐Day TapRooT® Course PhD: ???
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PhD in Root Cause Analysis
1. Advanced Trending Course 2. Equifactor® 3. So[ware Course 4. Stopping Fatali\es Course 5. Proac\ve Course 6. Summit (Every year!)
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PhD Discussion Topics
1. Using Safeguard Analysis to ID Causal Factors 2. Geang Management Support 3. Making a Management Presenta\on 4. Finding Generic Causes 5. Becoming Proac\ve 6. Proac\ve Performance Measures
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Plan Investigation – Get Started!
Determine Sequence of Events
Define Causal Factors
Analyze Each Causal Factor's Root Causes
Analyze Each Root Cause's Generic Causes
Develop & Evaluate Corrective Actions
Present / Report & Implement Corrective Actions
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Root Cause Tree®
Equifactor® Safeguards Analysis
Corrective Action Helper® SMARTER Matrix
TapRooT® Software
Spring SnapCharT® Root Cause Tree®
Summer SnapCharT® Equifactor® CHAP
Change Analysis
Safeguards Analysis
Root Cause Tree®
Corrective Action Helper®
Winter SnapCharT®
Equifactor®
Autumn SnapCharT®
Using Safeguard Analysis to Find Causal Factors
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Hazard (Energy)
Safeguard Target
Finding Causal Factors Using Safeguards Analysis
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Height
Electrical Mechanical
Chemical
Pressure Thermal
Radiation
Biological
Noise Muscle Power
Energy = Potential Hazard Chain Brake
Drum Design
Mechanical Integrity
Time, Distance, Shielding
Insulators
Hearing Protection Lifting Training
Fall Protection
Cool Vest
Sharps Bins
Control of Energy Keeps You Safe
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Develop a Hazard / Safeguard / Target Table
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1. What error allowed a Hazard or allowed it to grow too large?
2. What error allowed a Safeguard to fail?
3. What error allowed a Safeguard to be missing?
4. What error allowed a Target to get too close to a Hazard?
5. What error allowed an Incident to become worse after a Hazard contacted a Target?
Identifying Causal Factors Using Safeguards
Hazard Target
These mistakes (errors) are most likely Causal Factors
Identify the Hazards / Safeguards / Targets, then ask the following questions:
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Geang Management Support
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Making a Management Presenta\on
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Finding Generic Causes
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Becoming Proac\ve
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Proac\ve Performance Measures
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