Starting an RCA Program from a Mess
One client said, “We have 40 years of sparse data, no investigation records, I don’t have anything to benchmark.” Here’s how to process and build your old investigation program(s) as a context for implementing a TapRooT® RCA Program. Do NOT throw away that data, but mine it to develop a rich picture of missing vs used best practices (root causes).
Easy / Fast – Grade a Few Old Investigations
One client going through a TapRooT® renaissance used the TapRooT® Grading Matrix to grade a flagship investigation they considered excellent. Outcome: <50/100. Ouch!
This one representative investigation quality grade set many important benchmarks:
- State of the program – here is where we are
- Expectations were set ↑↑↑ in accordance with a formal standard
- Continuing training deficiencies identified – specific learning objectives need improvement
- Review, approval, implementation, and tracking for corrective actions were poor or non-existent
- No clear standard system for investigation completion was used
This list is a proactive identification of a program missing best practices that could lead to repeat incidents due to poor investigations. The next step here is a cure RCA of a poor investigation grade, and prove the program improvements that need to happen.
Investigation quality grades are a LEADING indicator of RCA program overall health and effectiveness.
Disciplined / Effective – Map Pre-TapRooT® CAPA Tasks to the TapRooT® Root Cause(s)
Even if no documentation exists for previous investigations, you probably do have a list of Corrective and Preventive Actions (CAPA).
Without TapRooT® Software
- Open your CAPA spreadsheet and put CAPA items in column A.
- Using your Root Cause Tree®, Dictionary, and Corrective Action Helper® Guide “Checks”, choose one TapRooT® root cause that best matches the CAPA in Column A.
- Enter that Basic Cause Category in Column B, Near Root Cause Category in Column C, and Root Cause in Column D.
- Grade the level of each CAPA using the Safeguard Hierarchy (or the Engineering Hierarchy of controls) in Column E.
- Build four Pareto charts, one for each of columns B-E.
With the TapRooT® Software
- CREATE NEW – Action Plan
2. Start logging CAPAs under that action plan.
Final step: list which CAPAs are redundant and combine them into a single action, or do a generic cause analysis to find an underlying systemic issue.
Proactive – Analyze Other Accidents
Analyze reports from accidents in your industry to determine best practices that may be missing from your company.
Simply take a previous incident at your company, or a best-in-class company in your industry, through the TapRooT® System. This will bring many questions about best practices.
Contact me (clark@taproot.com) and I will walk through an example of an oil refinery explosion to missing best practices, and other questions I would have wanted to ask or see evidence on.
Hint, hint, nudge nudge – every TapRooT® student finishes the course by taking an incident they are familiar with through the system.
If this is your first look at TapRooT®, register for a public course, or better yet, our Global Summit on Root Cause Analysis.
If you know TapRooT® Root Cause Analysis already and your organization is committed to improving, schedule a private on-site course with your strategic advisor (and also come to the Summit)!
