October 25, 2023 | Ken Reed

Why Are You Saving TapRooT® RCA For Major Incidents?

major incidents

I teach TapRooT® courses all over the world, and I often start my classes by asking the students, “How often are you performing an RCA at your company?” A common answer? “Luckily, we don’t have that many major incidents at our company, so we don’t do too many RCA’s.”

This answer is missing the boat on performance improvement. It still amazes me to hear that many companies are reserving TapRooT® to use only on their large investigations. For smaller problems, they’ll use “something else.” This usually means some less robust method, such as 5-Why’s or a brainstorming variant.

Let’s take a look at how waiting for major incidents to occur is probably not the best improvement strategy.

Why are they waiting for a major incident?

There are several reasons I’ve been given for companies deciding to use low-quality RCA on smaller incidents. When I say “smaller,” I find most companies have internally defined what this means. They usually use some type of risk/consequence matrix to define different levels of incidents, and therefore the tools they use for each of these levels. The smaller incidents are normally those that have smaller consequences (less severe injury, smaller equipment failure, less important quality deviation, etc.). The matrix usually then requires TapRooT® when they want great answers and some other method when poor results are acceptable.

Now, many companies might take exception to the way I describe this. They’ll explain that they never want to get poor results; they just allow other methods that are quicker for lower-ranking investigations. However, if you read this closely, they are saying EXACTLY what I said. Their matrix acknowledges that TapRooT® is a better method (it’s required for major investigations). If they cared about the quality of their “minor” investigation outcomes, their matrix wouldn’t specify the 5-Why and brainstorming variants. They would always use TapRooT® Root Cause Analysis.

Why do companies continue to use these less robust methodologies?

I hear several excuses:

  • “TapRooT® might take more than a few minutes.” Yes, this is true. There is no RCA method out there that will give you good answers in only a few minutes. I hear people doing 5-Why or brainstorming exercises in 5 minutes. What does this tell me? The team did not gather any significant information or evidence, and they are therefore doing an analysis based on their knowledge of the problem. They haven’t interviewed anyone, they haven’t gathered any real evidence, they haven’t tried to understand what happened. They will therefore get REALLY quick, but REALLY bad root cause(s), and the subsequent corrective actions will be useless.
  • “I don’t have the resources to do TapRooT® investigations on everything.” I’m not necessarily advocating that you do a TapRooT® investigation on every paper cut. It is legitimate to have an investigation matrix that specifies that very low-level problems might not warrant a full investigation. Just correct, categorize, and track the very low-level issues, and do a good RCA on those things that require any type of investigation.
  • “We don’t have that many incidents at our company.” I’m thrilled that your company does not have many major incidents. That’s a good thing. However, that doesn’t mean you can’t investigate smaller problems using robust RCA.
  • To go along with that, if you don’t think you have any problems at your company needing investigations, then you aren’t looking very hard. EVERY company has problems that don’t necessarily show up as major incidents. There are all kinds of precursor incidents happening at every company. If you haven’t seen them, it’s because you aren’t looking.

What are the advantages of using TapRooT® for smaller problems – not just major incidents?

  • You fix problems with a reliable methodology. You can trust the results you’ve gotten.
  • You are avoiding the major incidents. If you fix the small precursor issues, you are eliminating the mistakes that, In the future, are probably going to lead to a major issue.
  • You have avoided the blame that normally results from poor RCA methods. These other methods are not root cause analysis. They are often just identifying a mistake, and then applying corrective actions to that mistake. If someone makes a mistake, and you just apply a corrective action, you are probably blaming the person for the mistake. The corrective actions almost always place the burden on the employee. We tell them to be more careful or don’t make that mistake again. Pretty useless corrective actions.
  • You get more practice using TapRooT®. When you investigate smaller issues, you are performing more investigations. These smaller investigations can be very quick to perform since the problems are not very complicated. You get to do fast, simple investigations more often, which ensures you are ready to perform those more complex incident investigations when needed.

Don’t wait for those major incidents to occur. Get the full benefits of your TapRooT® implementation by using it as much as possible, getting more robust results, avoiding blame, and accelerating your improvement programs.

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