Root Cause Analysis Tip: What Can Go Inside the Event Shape when Mapping out your SnapCharT®?
Whether doing it by hand or in our TapRooT® Software, what can go into the Rectangles that we call Events (Who did whats or what did whats that occurred during the timeline that you are investigating)?
Who s:
Actions by the Operator, Mechanic, Manager, Vendor, Supplier, Contractor, Technician, Customer Service Rep, Engineer, Designer, Nurse, Doctor … as you can see the list is unlimited but understanding the who (we use job titles only) helps us to see if the who was setup for success prior or during the action he/she performed.
Whats:
Caution ( … this may not be what you expected or have been doing)
Equipment Actions: Relay opened when energized, Butterfly valve stuck shut, I.V. bag port become blocked with debris, fuel gravity fed into container through piping …
Hint: If working with equipment, pull up the equipment and system functional diagram up immediately to help you map out the Events.
Chemical Process Actions: Catalysts heated up, hot mix heated up …
Transactional Process: Purchased order received by customer service, SAP sent late warning to warranty …
Hint: Yes, you can follow a piece a paper, hazardous material shipment.. that is handed off from person to person just like you would a person.
Hopefully, this should open up your investigation options even more! By the way, I even mapped out the actions of a horse and a monkey which was analayzed under Human Engineering.
