Best Practices for Fast Analysis of Small Problems

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Best Practices for Fast Analysis of Small Problems

• By Sanjay Gandhi
• TapRooT Instructor
• TapRooT Summit
• Gatlinburg, TN
• April 7th 2006

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Discussion Topics

• Problems with Ineffective RCA
• Lets set the scene
• Getting Better at Fast Analysis of Small Problems
• Sharing of Best Practices (Group Discussion)

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Problems with ineffective RCA

• Recurring incidents and repeat investigations
• CAs that address symptoms not root causes
  (SMARTER)
• Rejection of investigation by management due to
  lack of depth in RCA
• Citation by regulator (OSHA) for poor
  investigation/ inadequate RCA
• Major fine/facility shutdown over regulatory
  issue that could have been corrected earlier by a
  good RCA
• Prevention of major accident if RCA of smaller
  ones were more effective

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Lets set the scene.

1. Key objective of an investigation is to develop
   corrective actions that will prevent future
   recurrences
2. Strive for efficiency, effectiveness and speed in
   RCA
3. Focus on the process of RCA and get proficient in
   it rather than its results

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Therefore if youre looking for a faster way to
resolve small problems using TapRooT..
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Getting better at fast analysis of small problems

• Sufficient TapRooT training for the
  investigation team
• Over train investigation team leader and team
  members
• 5-Day Course Team Leader
• 2-Day Course Team Member
• 3-Day Equifactor - Team Member (equipment
  analysis)
• Perform at least one investigation a month
• Attend TapRooT refresher training every 1 2
  years

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Getting better at fast analysis of small problems

• Assign an adequate number of persons to the team
• For large investigations maximum 10 and
  sub-teams for specific purposes
• Small problems One to two team member(s)
• Team member composition
• Team leader
• Technical person familiar with process/work
• Person with influence/authority within
  organization

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Getting better at fast analysis of small problems

• Use of efficient team strategies
• Spring SnapCharT for planning
• List of interviewees and times
• Redrawing SnapCharT outside the team meetings
• Keep separate investigation and meeting to-do
  lists
• Track investigation hours for efficiency and
  effectiveness checks
• Ensure sufficient management support for the
  investigation

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Getting better at fast analysis of small problems

• Seek external/internal help when needed
• Metallurgical analysis
• Oil analysis
• Human factors analysis
• Outside expert facilitators
• Technical experts, etc.

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Getting better at fast analysis of small problems

• Prepare for investigation before
  incident/accident happens
• Read Appendix A of TapRooT Book

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Getting better at fast analysis of small problems

• Use trending to spot developing problems and
  apply RCA
• Investigations should show a clear ROI
• Smaller problems should be trended
• DOES THE INCIDENT NEED INVESTIGATING?
• Management guidelines for investigations (serious
  accidents, serious incidents, incidents,
  recordable event, etc.)

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Getting better at fast analysis of small problems

• Stay up-to-date with current investigation
  practices
• Attend the TapRooT Summit Best practices
  sessions
• Interaction and Networking

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Getting better at fast analysis of small problems

• Use TapRooT tools effectively to improve
  efficiency
• SnapCharT software
• Access to Root Cause Tree is a click away
• Investigation results recorded whilst performing
  RCA
• CA Helper provides ideas for developing
  corrective actions
• Equifactor troubleshooting tables for equipment
  troubleshooting

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Getting better at fast analysis of small problems

• Get employees trained in the basics of RCA
• Enables saving key evidence
• They provide better information at interviews
• Suggest paths to help investigation process
• There is better buy-in for corrective actions

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Getting better at fast analysis of small problems

• Get management trained
• Avoids ineffective or counter-productive
  corrective actions dictated by management
• Stops them spending huge sums fixing problems
  that may not exist
• Stops them from saying theres a bad trend..
  when there is little data to detect a trend
• Training should be customized to meet an
  organizations most pressing challenges

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Please share your best practice(s) for fast
analysis of small problems with the groupThank
you!