2014  Global  TapRooT®  Summit  

Horseshoe  Bay,  TX  

2014  Global  TapRooT®  Summit  

Changing  the    Way  the  World  Solves  Problems  

Get  Your  RCA  PhD!  

Mark  Paradies  President,  System  Improvements  

The  TapRooT®  Folks  www.TapRooT.com  

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:

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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