February 15, 2012 | Barb Carr

Root Cause Analysis Tips – Using Safeguards to Find Causal Factors

Finding ALL causal factors is extremely important.  In our courses, we teach a number of best practices for finding those causal factors.  One of them is the 5 Safeguard questions:

What word is common to all of these questions?  Error.  And an error that fits these questions is most likely a causal factor.

Beyond using these questions to find causal factors as we teach in our 2 and 5 day courses, there is also a best practice we share in our Advanced TapRooT® Techniques course, which is to use these questions to collect evidence, here is an example:

A customer gets burned by coffee from a drive through (note:  any resemblance to a real incident is purely coincidental)

You do a safeguards table, just like we teach in the 2 and 5 day courses:

The hazard is hot coffee

The target is the customer

Safeguards include temperature, the cup, the lid, the cup holders in the car, and awareness

Now use the 5 safeguard questions, for example:

What error allowed a hazard or allowed it to grow too large?  This safeguard question might prompt you to wonder how hot the coffee was, how hot it was supposed to be, and what a safe temperature really is.  After you gathered all of your data and are ready to find causal factors, you might ask the question again:

What error allowed a hazard or allowed it to grow too large?

Coffee machine was set to brew at 190 degrees

Look there – I now have a causal factor, because that temperature actually causes 3rd degree burns within 7 seconds.  Ouch.  And the typical home coffee maker brews at 140 degrees.

So I hope this tip might help you to use safeguards more, ask better questions, save you time, and help you find all of your causal factors.  By the way, if you want to attend the Advanced TapRooT® Techniques course for more helpful best practices, there is still time.  The course will be held in Las Vegas on February 27-28.  Click HERE for more info.

By the way, here is some “coffee trivia” for you – why do restaurants brew their coffee so hot?

The most common answer?  “It tastes better.”  WRONG!!!

The real answer?  It smells better, which gets more people to buy coffee.

Thanks for visiting the blog and happy investigating.

Root Cause Analysis
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