Closing the Gap – Improving Incident Investigation & Root Cause Analysis
Challenge
Four years ago I was an incident investigator, an incident reviewer, and an investigation techniques instructor for our company. I found that many investigators, including myself, had some difficulty (or were inconsistent in) finding the root causes for incidents. We needed some way to consistently find accurate incident root causes to better learn from the incidents. Therefore our challenge was similar to many companies – we needed to consistently find the root causes of incidents.
We needed a tool that we could provide in our training that would guide investigators through root cause analysis without restricting the results. This tool should expedite and add value to investigations. It needed to be simple to use by people who did infrequent investigations, as well as for use in both complex and simple types of incidents.
All these requirements were a tall order.
Action
Fortunately, a colleague of mine had mentioned a system he had seen that might fill the need I had identified. I found out more about the system, called TapRooT, and decided to attend a 5-day course.
Once I saw they system in action, I knew TapRooT would work to help us improve our investigation. But how would we include TapRooT in our training and how would we get people to use the tool in performing investigations?
I decided that I would try TapRooT in several investigations and then share the results. Soon several colleague and my boss agreed it was a valuable addition to our investigation process. Our group decided to buy a license so that we could conduct our own in-house training. I became a certified as a TapRooT instructor and taught TapRooT as part of our companies investigation training.
Results
In the first three months that we offered the training, in excess of 100 people learned how to use TapRooT. The comments from the attendees after they investigated incidents were very favorable. The most important result was that the quality of investigations. My reviews showed that the investigation root cause analysis had improved considerably. The field personnel were using it, producing better, more consistent results. More and more individuals were asking for TapRooT training.
The use of TapRooT was never mandated yet it became the process of choice within our company. Positive comments have been received from employee representatives and managers.
Trying to evaluate the exact dollar cost savings of implementing TapRooT is difficult. Many good initiatives have been implemented as a result of our incident investigation processes. TapRooT has helped these investigation become much more effective. TapRooT helped us develop corrective actions that previously would have been missed. This has helped us prevent many costly incidents and has clearly contributed to our continuing improvement in our safety statistics.
Perhaps the best indicator of TapRooT’s success is its use throughout the company. In the four years since TapRooT was introduced, its use is widespread and requests keep coming for training. Using TapRooT is responsible for the continued improvement of our investigations and corrective actions. And we are now using TapRooT to finding root causes of audit findings.
As Manager of Health, Safety, & Environment, I consider TapRooT an essential part of our safety improvement efforts and our implementation of it a resounding success.
