Going Beyond Human Error with TapRooT® RCA
When Will They Learn?
“If we could just fix our people, we would stop having accidents.”
At System Improvements, we hear this all the time, but this statement misses a critical truth: mistakes make us human. The goal of an investigation shouldn’t be to blame individuals, but to understand why the system allowed the mistake to happen.
That’s why the TapRooT® RCA methodology helps investigators go beyond human error and beyond their own assumptions.
TapRooT® Incident Example
Let’s consider a simple example: an employee stacks boxes incorrectly, leading to damaged product. Many investigations would stop at “human error” or recommend retraining. But what if the employee was already trained? Retraining won’t prevent the problem from happening again.
This is where TapRooT® RCA would guide investigators to dig deeper by examining multiple system-level factors.
Work Direction
In this section, investigators assess preparation, worker selection, and supervision. Was the employee fatigued? Properly qualified? Adequately supervised? If fatigue played a role, the real question becomes, “Why did the system allow fatigue to exist?”
Human Engineering
Under the Human Engineering section, investigators would scope the work environment. Was there enough space? Adequate lighting? Good housekeeping? In this case, limited space or clutter may have forced the employee to stack boxes incorrectly.
Management Systems
The health of management systems directly affects performance. Are expectations clear? Are standards communicated effectively? Are audits performed to ensure work is done correctly? Weak systems often create the conditions for errors to occur. In this example, the stacking instructions could have been miscommunicated to the employee.
When investigations stop at human error, organizations miss the real opportunity to prevent future incident from reoccurring. People don’t come to work intending to make mistakes, but systems often set them up for failure. TapRooT® RCA provides investigators with a guided system to help dig deep, challenge assumptions, and help them go beyond their own knowledge.
Digging Deeper
Work Direction, Human Engineering, and Management Systems are three of many root cause categories we investigate in the TapRooT® System. Our process is an efficient yet effective way to solve human performance problems at their core.
Don’t wait for the next mistake to happen at your facility. Register for an upcoming TapRooT® Training course near you:
Continue the Conversation
If you’re new to root cause analysis, or you’re not sure where to get started, you can reach out to info@taproot.com. We’d be more than happy to answer and questions or schedule a call with you.
