June 7, 2023 | Mark Paradies

Investigating the Root Causes of Procedure Problems


TapRooT® RCA Procedure Investigation Guidance

TapRooT® Users … How do you investigate an incident that includes a procedure problem?

Easy! There is guidance on pages 170-172 of Book 4: TapRooT® Root Cause Analysis for Major Investigations.

Book 4

The book has these eight steps to investigate problems in the Procedures Basic Cause Category:

  1. Get an unused copy of the procedure.
  2. Get the completed, signed-off or checked-off procedure (if sign-off/check-off is required).
  3. Get any reference material/documentation.
  4. Was the procedure used?
  5. Was it signed off properly?
  6. Verify the technical accuracy of the procedure (table-top review).
  7. Verify the usability of the procedure by performing a field walk-through. (Consider performing a Critical Human Action Profile, Appendix F, and reviewing potential human factors problems at the same time.)
  8. If problems are found, consider looking for generic causes in the procedure writing and review system.

That’s the guidance for procedure problems. What about human factors, work direction, training, or management system problems? Book 4 has guidance for all the Basic Cause Categories from the back side of the TapRooT® Root Cause Tree®.

My Favorite Procedure Related Investigation Story

My favorite procedure-related story was an investigation where the team doing the investigation said that the person who was injured was using a procedure. I asked to see it. They said:

“You want to see the procedure?”

I said, “Yes.”

They sent someone off to get it.

They came back with a brown paper grocery bag.

procedure on a brown paper bag

They handed it to me.

I said, “What’s this?”

They said, “the procedure.”

I looked in the bag. There was nothing inside.

They said, “No look on the outside of the bag.”

There were handwritten notes on the outside of the bag. Mainly equipment part numbers. That was …

The Procedure.

The person who was performing the work had written a list of what parts went in which crates for shipment. There was no procedure for doing the work.

Lesson Learned

ALWAYS ask for the procedure when someone says that a procedure was used. You might get a good laugh too!

Learn More About Advanced Root Cause Analysis

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