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    DOC000

    Uploaded by

    Alizamin Syed
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    © All Rights Reserved
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    TapRooT® Corrective Action Helper® Guide ENTIRE CONTENTS © Copy BY SYSTEM IMPROVEMENTS, red fematona ow Vellore ar table or ein! end ul prosecute PRINTED INTHE UNITED STATES OF AMERICA . ‘ofaTe cae nie a 3 o ESTESELTTISSTTSELECETTSSS SSS ESTE apt Sm gr he USING THE CORRECTIVE ACTION HELPER® GUIDE TABLE OF CONTENTS Using the Corective Action Helper® Gulden - TOPOF TREE sn 3 Ides (or Suing Genetic Causes: 1 reminds the investigator t look for ‘Gener Root Case nd aga ways ofa genese Seen QUALITY CONTROL nnn fs No epee nono cen a ‘COMMUNICATIONS ~ ‘The Corntiov Acton Hojer® Guide doesn’t provide the fis No Comm. or Not Teton 0 ies Toe ene gob yout uate aera es TUmoVer Ninn cL [arormanc We hop Wis ook gs your cet jes fing, When dn Misunderstood Vertal Comm... as ‘scone that ae mth non fletne annoes See e y cormecive MANAGEMENT SYSTEM 2 SPACN nono SPACNot Usd. 8 Oversight / Employee Raton. au © te eo Cae fe sng ok or te ane Cometve Atle oo 17 ot Cas ary in te Sc te HUMAN ENGINEERING ae mar Machine lea 12 Work Enviroment vomoonoono 1s om Complex Sytem as Nor alt Telerant yom : ae sn tproctcom WORKDIRECTION cecnrrnn166 PD 0s iprreensn ted Sere = seas - - - . Twtecomccnagciee Gy HHP Srna ne Level I: Top of the Tree ‘Check: You have decided tht this problem wascaused sbSSISIIISESSISISELELE SSS SESS 333 33 fence em iu ate oa ‘Check: You have decided that the cause of this problem |s not covered by the Root Cause Tiee®! or the levormaton you have is isulicient to perform root eas: 1 Bffectivecoretve actin based on root cause analyses not possible 58 You progress furter down the Root Cause Tree, 9p corrective actions based on your Improvements at (865) 538-2139 to report rediscovered lens so that Your analysis can more effectively pinpoint causes Video and voice recording, aswell a data recorders, should be considered, Checks You have decided that this problem was ‘auced by a Natural Disaster or Sabotage. LEVELS 1 - 5: Equipment Difficulty Check: You have decided that this is random ‘cqupment failure that is dificle to predict and not wort xg, For cass of sabolage you may consider providing your information| have decided that this equipment problem is NOT worth to he proper authors fora criminal investigation equipment problem faxing. ‘Therefore, no corective action s recommended beyond replacing the Referen AL Insider Tra: Prot srr fom Sabla, Spying, and Te. (2006) by Eric Cole and Sandra Ring published by Syngress. ysis of unexpected ales a PAIIISIIIISITSISSELESSELSSSSIISSS! Ue failure rato tat you can detec tres, 4 PRESS eect ter sesenate cine rewde to bs improved to prevent fai failures “ ese 1. You should continue to analyze the cause ofthis problem to find the rot cause ofthe design problem. : ‘conchae ae cig Sonn go 2 Ee 2. You will then consider redesigning the equipment or conducting You have decided that the design of the tyuipmet should be Improved to prevent Future ripenent fares, ern has wo apes that ned to be considered, Fret the problem 7 design and, second, the problem with the design proc 1. Fiat, you should consider recommending redesign ofthe equipment ‘inate the problem nteduced by the design specficntion deficiency. 2 Second, you should continue to analyze the cause ‘night belo consider changing the guidance given to engineers who ‘develop design specications or Gener Pro there isa genetic problem, you should consider changing the esgn proces or the aling for engineers to reduce the iksinoed of ‘engineers making this type of design eror in the tue 1 efetecomcinkcinwecan Se References: 1. Code of Federal Regulations (Pharmaceuticals) 27CFRM Sutpart D, ade’ Ap rcs Deg fy Chi nd Pech ton, 2007) by Emest E Ludwig published by 2007) ATEX 94/9/EC, European Union. ‘Checks You have found tha the design specifications for this ‘sjuipment need improvement. This pcblena has two areas that need tobe considered. First the problem the problem ith te design precess. 1. Firs you should consider recommending redesign ofthe equipment to eliminate the problem introduced by the design spesficaion defeieny. the couse ofthis orablem tion problem, One ides ‘develop design specifications, eas fer Generic Problems: oblem, you should consider changing the ning for engineers to reduce the {6 Mechanic xd Electrical Equipment or Buildings, 12th Ei 5 Federal Regulations (Pharmaceutical) 1CFROI Sbpit D, Benjamin Stn tl Petosemic! Plats, Salty Standard AS 40241-2008 Seis «Say of Machinery, (2007) by EenestE. Ludwig, published by 4 sig con/sbop/Srip Dat asDaN- ASTER inMalkin, published by Wily ent igs Ein, ON} y published by Wiley. Consider recommending an improved design that eliminates the problem hates not antcated er investigation to determine the 1001 causes of the reason tha the designer did not anticipate the problem and he design reviewer didnot detect the problem. 0) by Eres Ladi peblsh by ishing Ideas for Gener Problems: 1. You should iy to identify the Generic Cause of the designer not recognizing the problem and consi ‘Cheek: You have decided thatthe design specifications ‘were OK, but the dsign didnot mest the speciation, dens 1, Consider recommending an improved design that meets the specs 2. Consider the oot causes ofthe desig not meeting the pecs Ideas for Generic Problems 1 wre isa generic problem, you should consider recommending say impor the gprs eign review. ec 3. Medical Deve ant Ei Ergonomics, 0995) by Michael E. Wi 1. Code of Federal Regulations (Pharmaceuticals) 21CFRIN Subpart D, an Desi, (2000) Equipment. » al, published by Gull Professional Publishing. 2 Asai uly Sand AS 4241 206 Se ty of May, \wivsiglbal com shop/ Ser f Design: Usability Engineering and Ergonomics, (1988) by Michael . Wiklund, published by CRC. Scan npn , ‘Cheek: You have decided thatthe design needed improvement because ‘the designer did not anticpate a problem with the equipment's ‘operating environment that should have been anticipated Ideas: 1 You should consider cither recommending an improved design that sll work in the intended ronment or modifying the ‘equipment envionment to make te environment acceptable fr the ealeting equipment. reason tha the designer dd nt anticipate the problem and the design reviewer didnot detect the problem, Ideas fr Generic Probl 1 You should ty to identify the Generie Cause of the designer not and consider recommending ways to improve the design ‘design review, or taining of the designer to reduce the ikethood that designers will make the same typeof mistake inthe future References 1. Code of Federal Regulations Pharmaceuticals) 21CFR2N Subpart D, Equip 2. Australian Safety Standard AS40241 205 Series - Safty of Machinery, ‘wiwsigibalcom/ shop Script Deal asp?DocN=ASSISS7OS56 3. Medial Device and Equipment Design: Usability Engincering Ergonomic (195) by Michael. Wiklund, plished by CRC. . Tyfetb mc tae ae Check: You have decided thatthe equipment failure wa atleast partially caused by the desig reviewer hot detecting a problem that he should have been ‘expected to detect 1. Consider recommending an improved design problem that was overlooked in the design review, 2. Consider analyzing the root cae ofthe ule ofthe design review, iminats the eneri Problem: identify a Generic Cause of the design reviewer feral Regulations (Pharmaceutical) 2ICFR2I1 Subpart D, Safety Standard AS 241-206 eres - Sty of Miner, com/shop/Seript/Detalisasp?DocN=ASS2SE7DI SSE 3. Matin! Device and Equipment Design: Usability Enginering and (195) by Michael E. Wiklund, published by CRC, Section and Design (2000) Profesional Publishing, aa Ea Checks You have decided thatthe equipment failure free was the vier ava indepen fe frginal design Tess: 1. You should consider recommending an improved design that ‘imingtes the problem tat was overlooked inthe design review dens for Generic Problems: 1. IF nomindependent design review isa generic problem, consider recommending changes inthe process to improve the independence ‘ofthe design reviewer inthe design review proces References: 1. Code of Federal Regulations (Pharmaceuticos)21CFR2H Subpart D, Enuipment 2. Australian Safty Standard AS 40241 2006 Series - Safty of Machinery, ‘revatiglbl com shop /Scrip/ Details aep?DoeN=ASS2S87ON 536, ‘Metical! Device and Equipment Design: Usability Engineering and ‘Check: You have decided that an independent review ofthe design change {Management of Change or 5059 review) would have detected the problem with the design modiation and thereby would have prevented the prober, » ‘ere cna Gate anny "lures to se the Management of Change policy, ‘gveric problems inthe next section. aifected personne 3. ‘To ensure that the changes you are implementing are adequate and continue to be properly applied, consider implementing a catinuing petlodic audit ofthe Management of Change prorat, 2 The Centr for Chemical Proce Safety has numerous references with dete ideas on how toinprove your Management of Chg: pres. See hip /wwwalcheory/CCPS/indexasps 3. Gains rhe Management of Change fr Pros Safty (2008) 1st Eton, Cente for Chemica Process Safty. New York SBN S78 170013007 prevented the problem. cnr Sy Sem tponeat ® So hare was no adequate policy for conducting a Hazard Analyse, the policy requting Hazard Analysis was not used because the people responsie did not understand the policy, consider careectve tion under the Training li there are repeated al generic problems inthe ‘Once you have comet the prblems with your design and Hazard Aly progam, conser conducting taining forall affect! personnel atosioomenereiuoae gy Guidelines for Hazard Evolution Procedures, 2nd Eaton with Worked Examples, (1982) Centr for Chemical Process Safety, New York ISBN Sre-oB1co0IN8 Process Quantitative Rsk Analysis, (2000 2nd mal Process Safety, New York, ISBN 978- 1. Continue analyzng the rot cause of thic prem. Then corsider 1 ean’ fnd he cause ofthe equipment consider redesigning the equpaen tive par. Process Control (SPC) may be helpful in analyz cquipment/ parts defective and in developing cor ation about SPC, read. Und ling, you may ‘Checks You have decided that defective or improper parts or equipment were obtained fom a vendor 2 pe pm a Gtr 3. Consider performing cular procurement hazards and its impact to operations. oping coretve actions forthe defectvs pat evs OF ible performance. The {goal ofthe review would bet identify programmatic fixes that would aur beter purchasing performance in the fore wiper, (1998) by Jon Mahoney, published by Chain Manogenent: A Hondosk fr Static Proce, lefrey Wincel published by Productivity Press. Procurement and Supply Manager's Deck Refrnc, 2012) by Fred ‘and John Semanik published by Wily. 44 Purchasing: Section and Procurement forthe Hospitality Industry. (2012) by Andrew Feinscin and John Seaneli, published ty Wiley. 2% E-Prnurment: Fran ution, (20) by Uae Net, published by FT Press, {Check You ave died that pas or equipment ee oo ie Se alin fone smanufseturer « ‘este como a eas: ; 1. Consider replacing the defective par, (Caefll I you get «new part from the same manufacture orf the same mano te new part may also he defective. Consider pre instllaton teoton, tovensue that the part works as designe, 2 Next. if you want to ensure that the manufactrer improves thir rocess, get them to analyze the root causes of thelr mamufacrog ‘Sifts [Nextt identify the rot causes ofthese handing problems, SnapiCha transportation tand froma lection ings part tr stupping "ype shipping containers EC Tiiieniamemiereenad = fragity SSDS or other hazards and safeguards dese for Generic Problems 1 reusage ~ welght/height/centerof gravity froglsy SS or other hazard an safeguards ‘eas for Generic Problem: 1 yu nd that storage of pars and quent ia gna problem, con ymmmending a review ol the problem was at least patlly caused by the fallure to perform reasonable Inspections, functional tests, of ually ‘enfeation checks the checks that were performed failed to detect the problem when & fesonathe check should have caught eas 1. You should continue to analyze tis problem until you fd root se. You can then correct the roo cases, ca tidenify the rot causes thn perform a Safeguards Analysis apter 10 of the TpRaaT® Boat, 208) 0 ident potential Safeguards that could rece the kethood ofthis problem searing, improved inspections, unetonal ets, ly verifications even if you dont know the root ease of his . Be careful that you dow’ try to use inspections to fx ever problem. Instead, you may want to consider schae Satie liminate the potent cap 5 Semin he you od of ths problem recurring without ‘equting an adional QC check, eas for Generie Problems: you decide that QC sa generic problem, then you should conser recommending corrective actions 10 eliminate the cause. These corrective actions would depend on the ‘One way to start the improvement process for a generic QC problem is to bene highly reliable performance. The goal ofthe review ‘would be to identify programmatic Fixes that would improve your (QC proces and lead ts improved overall performance, 0 should consider recommending a review of similar work workean be improved before a similar, bt diffe complexity ofthe tasks, consider recommending a phased sppro by prioritizing the work to be reviewed and addtesing the most important asks fast, ‘Check Your analysis has indicated a problem with the ‘squipment's preventive or predictive. mainienance rogram. ess 1 Elective corrective action based on root cause analysis would be ‘easier f you progress further down the Root Cause Tec®, IF you cannot progress further down the tee, then consider performing a Safeguards Analysis (Chapter 10 ofthe TapaaT® Bot, 32008 to identify potential Safeguards tht you could add Yo reduce ‘he keihood ofthis ncdent recurring ‘Toston nh 3. Also consider installing recording. equipment to record more in ture equipment flues so that you could beter analyze the oot causes ofthe fale and develop improved PMs i has indicated a problem with the ‘squipment’ preventive or pediclivemaintenance progam. Insed on root cause analysis woul! be down the Root Cause Tee, 3. Consider conducting a proactive Equifsctor® Analysis o identiy areas that may need PMs, See Chapter 9f the TopRoaT® Bok (2008, 4. If you had touble finding a root cause because the maintenance records and preventive maintenance docomentaion were unavatae, ioccuateand prevented you from analyzing the probe, consider recommending iprovemens to Une documentation system, t 10 record more at you could beter sproved_preventive/ predictive equipment involved consider ee) Sinn Once you have developed the nee program forthe partic providing. twain for the techni Sperators,supervitors, and managers supervising the maintenance. 1 technicians, mechanics, schedules, ‘managers wi willbe performing an 5 Genet Problems supervisors, and managers who wil be performing and Wpthe maintenance by FS. Nowlan and H, Heap, ion Servie, Springfield, VA visors, and managers who wil be performing snd ‘Supervising the maotonance PM to reduce he ikcihood ofthis type of equipment 1 1. Consider developinga preventive or predictive malntenance program forthe equipment Managemen for Matic Equipuent (ASHE), CCheck: You have decided that the PM forthe equipment needs improvement. cap rem n Equipment Dit References proving. the preventive or predictive maintenance ‘set significant equipment ‘Then recommend improved PM forall equipment that needs better maintenance nce you ave dewaped the improved prevented ‘Spervising the maintenance Rei centered Mei Pbliser Nationa Tech Butierworl- Heinemann MiG New ok Preontoe Maintnenc Good Practice Auth and Poblisher: [Nuclear Power Operation, Alana, GA. Maintenance Management for Media Equipment (ASHE ‘it Conc ce at You have decided that thisailureateistoo frequent te intended purpose of this equipment. Ideas Repeat flues indies that some other category oF categories ind over again. Consider continue to analyze other equipment dificlly areas of se Trea to Find the root causes 3. IF you cannot find any root causes, then you should consider somucting a aegurds Aas (Chapler 1 the Top fot x Safeguards that you could add to reduce hood of lsincent rearing Ideas 1 You should continue to analyze the causes to find the root causes ina core acn hat ve andy ben deveoped ut have not been i Ea Checks You have decided that the problem was caused by falure effet cig tm remets ne a You should consider ways to improve your corrective acti You sil a to improve your corrective action system st you should consider implementing effective, timely corrective esl fr Ue problem that was not coreced that cased you 10 feet his rot eause. 21. Second, you need to consider ways to improve your corrective action ‘Shutmap thaeifestve, timely coreetie ation are implemented for lente problems. 13. The types of corrective action® needed depend on the reasons for ive ections not teng implemented. Therefore, wveaigation to identify yig wauidinba jure to implement effective, timely corrective continue ¥ to identify are causing the Zomective action system fofalland thenmplementeffectvecomective Seton to improve the system, ‘Check: You have decided that the coretve action recommended in the improved. (This may include a lack of corrective eas: 4 Recommend effective corrective actions! Before you can do this you fhe To understand the root causes ofthe problem. Therefor, you ‘Should continue to analyze the problem's root causes. 22. Statstial Process Control (PC) may be helpful in analyzing the failures and in developing corrective action. —_ ‘then you should consider MD 7. Once you have ident alysi (Clapter 100 get tion proces, you Safeguard that you s involved. re others inyour industry or eter industries campy Sm ema wut System Improvements’ independent ‘and corective action system cll (865) pulse by $C rss Knowl 7 ‘Check: You have decided that tive action fora problem thet was ‘previously identified was not implemented soon enough. Ideas: 1 lat, x the specific eause ofthe repeat re Consider recommending action fo expedite the implementation of the already existing corrective action «= Consider recommending interim compensatory action that can be implemented inmediatey as 8 stop-gap messure (even though it des for Gener bles "Yor ned to colder ways to improve your coretive action stom review ofthese processes with an eye toward a process redesign s ‘concn haa ie ction tracking system be implemented fatrocking system wasn place but management putsnoemphasison Jimplementng corrective actions, you should consider» manager bring how the lack of emphasis impacted this incident dependent of rot cause analysis and corrective action system, cal and implemented that would have prevented this incident, eas 1. You should consider recom rogram a coret the proble provements to the trending 1deas for Generic Problems: ny 5 Sm nema 2” References 1, Tapkao Toot, (2008) by Mark Paradies and Lind Unger, published by System Improvements, Knowille, TN. Call (65) 508-2139, see \whwttaprootcom, of emallInfoataproat.com, For more information sbout SPC ex ce ia Press Contra, (1982) by Donal J. Wheeler bers, and published by SPC Press Knowle TN, |4. For teining on improved trending attend the 2-Day TapRooT® ‘Advanced Trending Techniques Course. F taproot com, or cll (85) 539-2138, or email info@taproot.com, LEVEL: Human Performance Troubleshooting Guide {05 Questions) ES {he root caus evel eas: Effective corrective action based on rot cause analysis fe not posi unless you progeess further down the Root Cause Toe, 2 If you cannot progress further down the tree then consider performing a Safeguards Analysis, ofthe TaphooT® Bock, fentify potential Safeguards that you could add to reduce dent recurring You are investigating an equipment problem, consider using Equifactor® to troubleshoot the eae ofthe problem. » ‘efoto a ew a AUIISITULISITELELEELEREREEESE RES wa LEVELS 3-5: Procedures, Check: You have decided tha the prob was related to writen procedure us, ack. waiter procedure, of misuse of a writen precede, dese: 1 You shoul contin to analyze the cause ofthis problem to find the oot se ofthe procedure problem. You ean then erect the root causes rca ently the oot auss then perform a Sfeguazds Anal ptr 10of the Fao Bol, 2008) tient poenl See that you cull ad to reduce the likelihood ofthis problem recuring, 5) 0 fx every problem, human foctred designs human factors design the procedure recommending training people n should consider ecommending traning a that you make forthe people who wse the 1, For more information about the theory behind proce Writing effective procedures, we recommend attending the & Day Tapkoot® Adv ‘Cause Analysis Team Leader Teining For more information cal (865) 539-219, or soe svrwiaproct com) course php 2. Also, you may read Prcsure Writing Principles and Pr by Douglas Wieringa, Christopher Moore, and Valeri, usage and ‘Check: You have decided that properly using «procedure to perform histask would have prevented or sipificanty redlaced the consequences ofthis inelden, cep 55 Smee a eas: 1. Before using a weaker safeguard such as 2 procedure to core the sue, you should also consider using by removing the hazard, removing the uation, or guarding the person o ‘You should continue to analyze the cause ofthis problem to find the rot cause ofthe procedure problem. You ean then correct the root 3. Ifyou cant iden the rot causes, then perform a Safeguard Analysis Ideas for Generic Problems: 1. If people not using or not following roceares ita generic problem, you should conser implementing program to cortet the problem 3. Also, you would probably perform ed audi o reviews to dently ‘Toot causes of procedure usage problems, 4. Then you would develop a procedure ‘based on your observation, root cause ‘managers and employees. You wt ‘sppropriate training fr those lected improvement program fn discussions with » ‘ri Concha kcoa AAT! instituting continaing procedure usage ements worked and Yo Kenly any nev nd Procedures, (2010) by Stephen Page, ment Publishers 2 Prac Whig: rns nd Pree (199) by Dougls Wrings Ghrstopher Moore, and Vee Barna, pbliced oy Btls Pes, uma nl 3. Forme ination othe thay tend procedure usage and wtingelletve proctor, we commend standing thes Dy TapkooT® Adrants Root Cone Aras Team Lander aig. er Inova cal 5929s vr apenc/cus y Former develop proce a onic St proven yal Check: Your analjsis hat shown that this work ane you have decide Improve performance ofthis tsk Ideas 1. Sefore using a weaker safeguard such at a procedure to comect this issue, you should leo consider using the Safeguards hierarchy ard, removing the t the person ort ‘You should cansider recommending the development ofa procedure top task bee procedure. For exam. Froblems or poorly human factored designs canbe Ocay6 by Sperone » ted to be overcome by providing detaed procedures to “work eet . Interface consider improving the ergonomics or human factors de- sign ofthe equipment rather than trying impeove the procedure. include taining Consider including inthe tring the reason or the procedure, proper sage ofthe procedure and any skills requted to use the procedure Ideas for Generic Problem 1, Ifyou find that lack of procedures is a generic problem, consider 1 Buldance for operations and maintenance 35 when they should have procedure fo pe 2 Once you have developed guidance for when a procedure should bbe used, you may consider performing «systematic assessment of the tasks performed to decide which ones need to have procedures developed 3. Once you develop new procedures you would conduct taining for maask. References: or information about the theory behind procedure usage and i elective procedures, we recommend attending the 5-Day 5T@ Advanced Root Cause Analysis Team Leader Training. For more information eal (85) 838-2139, o see wwwiaproctcom/ eas: 1. You should consider recommending, ways to make the procedure 2 ‘ets Cmca ap se le copies ofthe procedure, or dng the procedure user with some electoni or audible frm procedure (Once you ave found how to make the procedure avallable to those who need io use consider recommending taining fr the users to explain What you'vedane and why iis important for them touse the proce for Generic Problems I you find that the avai consider ecommendinga: change the makes al procedures ‘more available tothe people who need fo se them, ‘Don't forget to train people about the changes thal they understand the way you are making procedures more availabe 2 Check: You have desided aicalt we We procedure was nat used because Iwas ider recommending ways to make the procedure rs, making each procedure easier to use depends dure, but hee are some ideas fo conser can be performed more efcelly confine complex decisions eral to make lt appropiate forthe ‘see beyond the curent procedures at they are secustomed to NOT using procedure isnot writen inthe native language of the use, consider translating the procedure, This can be aseparste procedure a) 3. the procedure isnot weit inthe native language of the user soncider having a Sr party review to replace welten instructions ‘wih pctographs where posite 1 you thnk aol ang could have raised the procedure wes tal levels atthe procedure would have ben sale, you should also ‘coneder commending tang for he personnel vo perfor Ue work ltyou thinkthat ational preparation forth work could haveraised As part of your recommendation, you should consider having users Field test he revised procedure o ensure hat it ieasier to use you cartfind a way to make the procedure more wabl, you may want toconsder reengineering the proces to change te works that the work ts ear to perfor ond the procedure easier fo une), This may requ changing the human-machine interfe or changing the prc yo ‘AS with all major changes, the ost ard benefit of al vedesign neds to be considered, But dont et the sana! response of“ Weve always ne it this wey" stop you rom considering innovative ways o change {he workor the procedure to make the procedure or the work es fica Alto, consider performing a Safeguards Analysis i dificult to wse procidure i the only barr betvoensoccess and serious accident. For more iyormation about Safeguards Analysis, see Chapter 10 of the TapRooT® Book, 208) Ides for Genetic Probleme: generic problem, procedure writers 2. Alto, consider recommending a complete procedure improvement prove the wsabity ofall Your procedures before Reference: 1 To Jean more about the proper way 19 write procedures to make them more usable, we recommend atlending the 5Day TapRooT® ‘Advanced Root Cause Analysis Team Leader Training, Por more “ ‘st car em bet ae information al (5) 539-2139, or see wwvtaproot.com/ courses php, riniples end Practices, (199) by Doug Wierngs, het Moore and Valerie Bares, pablished by Batlle Pes Columbus, Ohio. ‘Togothelp developing procedure improvement program call Sytem Improvements at (855) 39-219, procedure to comet Sxteguards her ld consider recommending thatthe procedure be required foe performance * Make the procedure a checklist and require the completed checlist to be atsched tthe completed «Have management and super use a procedure that previously he wear bo People tht change s nesded tn mom ‘ess for Generic Probleme: 1. Ifyou fied that failure to require thease of procedures is generic Suggested corrective action to solve this ype of generic problem the procedure was consciously not followed because deviation rom DIRE 305 ot 2 he proetre tat ws sed was wrong 1. You shout continue to analyze the cause ofthis problem to find out hhow and why the procedure was wrong You can then correct the rot causes and rewrite the procedure so that iis igh. 2 Remember to consider recommending taining for the procedure users about any coretions tothe procedure ou find that procedures being wrong is a generic problem, you should or you develop an improved procedure production that you learn. Final, wan the people Who write procedures on these new process, * TefsTecamcne scone References 1. For more information about developing good procedures, we recommend attending the 5-Day TapRooT Advanced Root Cause Analysis Team Leader Training. For more information call 855) 23% 2138, or see wwwtaprootcom courses py pes and re, and Valeri B ) by Douglas Wiring, he lished by Betele Press, Columbus, Ohio fecded that a typographical error was responsi fu have corrected the procedure, notify the procedure wsers yp as been corete y be a good time to reinforce the actions to be taken eure users ind mstakos (ke typos) in a procedure 20 takes can be corrected before an ineent onc eas for Generic Problems: 1. you find that typographical enors and other mistakes ae a generic procedure problem, then you need fo recommend changes to the procedure writing and review process to improve procedure qual 2. Ifyou find that typographical ertors and other mistakes ar a generic _rocedsre problem snd you correct the procedure system, then you ‘eed to consider recommending a general procedure improvenent program to remove the existing {pographial errs and other ‘mistakes rom the procedures, 3. Consider simultaneously implementing other improvements o the procedures, References: 1. Ty les methods for improving your procedures, attend the SDay Tapa Advanced Root Cause Aral le Lender Tring Fr Toe information eal 65 (oF se Wieetaprootcon/ curse pip. 2 Procure Wat: Principles and mci, (199) by Douglas Wierngs, Christopher Moore, ames, published by Battelle Press Columbus, Ohio, pm 8 Spemnp ef ‘Checks You have found thatthe problem occured because the sequence of he procedie eps was wrong eas 1. Consider recommending the procedure be madied so thatthe uence income ne Consider not only making the sequence echnicaly accurate bt a ‘plies the procedure so tha improves the efency of he work Maks sure you cose the pyc yout ofthe equipment and any homan tations 2 Once you have corrected the procedure, notify the procedure users {hat ie aequence hasbeen corrected 4. This may bea god time to sinfrce the actions tobe taken the re sts find misses ike sequence problems) ina proedie the mikes can corrected before an incient ocars efor Generic Problems 1. Ifyou find tat sequence problems and other mistakes area generic peedure problem recommend change to the procedure wring $e review proceso impeove the quality of your procedures 2 you find that soquence problems and ober mistakes area generic Procedieprebemandi you core the proceduresystem hen coer eommendings geal procedure Iprovernent progr i remove the cratng sect prblens ued ober mites Gon the rocties 2. Consier other improvements othe procedures be implemented a thesame tine References: LT leam methods for improving your procedures, attend the 5-Day ‘TapRoot@ Advanced Root Cause Analysis Team Leader Training (868) 539-2139, oF see wweetaproct.com/ For move information Teas: 1 You should consider recommending the procedure be corrected with the proper facta information, 2. Once you have correcta the factual content ofthe procedure, notify the procedure uses ofthe changes reinforce the actions tobe taken if the accuracies in a procedure so thatthe ‘stakes canbe coreced before an incident occa eas for Generic Problems, 1. you find that inaccurate facta content inthe procs i & generic Problem, commend changes tthe precede wring and review roan. 2 I you find that inacurate factual content is generie procedure problem and if you corect the procedure system, then you need {general procedure improversent program rent ofthe procedures imultaneously implementing other 3. You may wa Improvements to the precedures, References ‘To learn methods for improving your procedures attend the 5-Day TapltooT® Advanced Root Cause Analysis Team Leader Training For more information cil (85) 899-219, or see worwtaprookcom? courses php, 2. Proce lesan Practices, (1985) by Douglas Wiring, {Ghstopher Moore and Valen Barnes, published by Battelle Pre Columbus, Ohio, ‘Check: You have decided thal the procedure ale adress al stustions thatreasonably should have been expected to occur during completion ofthe procedue Ideas 4 You should consider recommending an addition tothe procedure that overs the situation that cused the incident ean mm em > 3. Once you have corrected the sope of the procedure so that covers AIT the situations that should reasonably be incloded, notify the procedure users 4 Also, tis may be a good time to reinforce the ations to be taken if ‘the procedure users find other procedures with omissions 0 that the ‘omissions can be corset before an incident occurs eas for Generic Problem: 1 you find thatthe scope of the procedures not covering situations adequately isa ner problem, then you needtorecommendehange: {othe procedure writing and review process, 2 Also, consider recommending, 2 general procedure improvement program te improve the scope ofthe procedures. 3. You may want to consider implementing other improvements tothe procedures tthe sme ime, ess improve the process or entering temporary procedure changes Some may suggest implementing an electronic procedure Ss that only the most recent procedure revision withthe approprite temporary procedure changes is avilable to be printed out, Proceed ‘witheauion The electronic system mast meet the needs of the user The 0 ‘iat conceit SSSESETEESESEETEEEEESUTESN100133) lectronic system must heat las ey to ue, if not moreeasy tus, il geceivein an outage or tarnaround (high usage operations). of procedures and what they ae supposed © do tomake the system work. References: Practices, 199) by Douglas Wirnga, ares, published by Battle Fess, Columbus, Ohio, 3.7 Steps to Bete Viren Policies and Procedures, (2001) by Steve Fage, published by Praes Improvement Publishing ‘Checks You have decided that a second checker should have been used 35 part of ths task and that ane should have been inladed inthe procedure eas 1. Consider recommending the use of a second checker ata part the procedure cag stm per ® 3d Incoreetl Using second checker fe not appropriate forall work. A scond person to watch works expensive and many would argue that decrees the pereived reper wpevidence that the works sodangerous or So mportan that abelate mistake se operation f required + ° eas for Generic Problems: 1 Because you probably won trecommend extensive use of second checkers itisunely thatthe lck ofa sound checker willbe gener: problem. If you find thatthe lack of second checker isa generic problem, You should consider changing the process to reac Consider recommending implementalion of some type ‘monitoring fo improve performance (ather than having dozens oF hundreds of second checkers). 2 Tw Comee Act te ese: 1. You should cantinue to analyze the reason thatthe procedure was Human Engineering and Taining sections ofthe tee 3. Ifyou cat identify the root causes in those sections ofthe te, then perform a Safeguards Analy Identity pote Steuart ofthis problem curring even ifthe procedures followed incorrectly. References: mation about the theory behind procedure usage etve procedures that can be followed correctly we wend attending the &-Day TapRoa “ean Leader Tesining, For more information cal 2 Procure Woking: Principles and Practices, (1999) by Douglas Wheringa, Christopher Loore and Valerie Barnes. published by Batlle Proce Columbus, On. Check: You have decided procedure was followed incorrectly because the procedure format kept the reader and relly understanding the procedures intent, eas ‘You should bacome familia with the procedure formats and writing techniques that make procedures ey to read, ‘Aso, you shuld be able to evaluate a procedure fr its grade level, ‘complesty and specifiy. le: ecommenng how to improve the procedure so that ‘mks the procedure easy to use Procedure users accurately and the native language of the ser, scan bea separate procedure With ictographs where possible [eas for Gener Problems: 1 you find that confusing procedure formats ae a generic problem, you should consider recommending the development of format the procedure is not writen in the native language ofthe ser, er having 8 Sed party revew to replace writen Instructions you corect confusing procedures, inform the procedure ses ofthe changes and why dhe changes were made, They also should understand ‘why the Format was chosen and how wl improve performance. that does References: ‘To lear more about improving the format of procedures, attend the approved procedure to be taken ifthe ink confusing oF ‘Check: You have decided that the problem occurred because a procedural tess step hed than one action (athe than in esp, single ston 1. You should consider recommending re-seriing the procedure with 2 linge ation in each step, ‘wacom conte 3333333333333333333333333999999992 2. If the procedure user recommending dh a. place in the procedure, consider check mark a the end ofeach {Ideas for Generic Problems: 1. Ifyou find that procedures having more than one action per step are 8 generic problem, consider recommending guidance for procedure 2. Also, consider traning the procedure writers 3. Also. during the review ofa new procedure consider check to make sure tht there fonly one action per step. fou have these genele coercive ations in place, consider ending a general procedure improvement program to remove ‘multiple actions per step fom the resto the facllys procedures 5. Once the general procedure improvement program is implemented, ‘make sure that you explain to the procedure user why the changes being madieand how th change ar inert oir pinta 6. Also thismay bea good time to reinforce the actions toe taken ifthe procedure users find problems lures with more than one ction per step) in» procedure s0 tht the problems can be corrected before sn ncident actus this gidance nga speci References: 1. learn more about improving procedures, attend the 5-Day TapRooT® Advanced ne Analysis Team Leader Training, For mere information call (85) 539-219, or cee worwtsprotcomy, courses php. 2 Procedure Whitin: Principesand Prati, (199) by Douglas Wierings, Christopher Meor, and Valerie Barnes, published by Batele Pres, Columbus, Oho, Procedures caused the user to eome confused, lose her place, or ‘mit steps in one ofthe multiple procedures. Teas 1. You should consider recommending a revision of the procedure to include all the information needed by the procedure user reducing the number of references) cops Sm npocen be “ Ideas for Generic Problems: 1. rexcessivereerences ares generic problem, your facil probably has a comple, interelsted procedure system. Simplifying the complex Interelating proced roces (Irough re-engineering) fa better solution, ‘Checks You have decided thatthe procedure user was confused by the Procedure containing references to multiple plans or units. ess: You should consider recommending the development of separate procedures foreach plant or unit 2 Once separate procedures have been developed, make sue that you ‘explain tothe procedure users why the changer are being made and how the changes are intended to improve performance 3. Also this may be a good time to relvore the aon tobe ten if the procedure users find problems (ike multiple unt wéeences) in a rocedures hat the probems can be conc bone an cent ours. “ ‘afer coment hp ate 1 1. You should conser recommending thatthe procedure be rewritten using absolute numbers to express ranges rather than a = humber ot ‘evample, the procedure ree: 18, Adjust the potertometer until the output meter reads 6 volts (e143) ‘Then you should recom 18 Adjuet the pot 65 volts (meter reading between 35.9 ad 2 People are notorious fer making simple math errors. Changing the ‘way you express these mits will lieve the procedure user of having to perform mental math find the coret limits, Ideas for Generic Problems, ou find that procederes having ranges expressed ina “4” forma i problem, consider recommending guldance for procedure ing the procedure writers about this guidance, new procedure, consider addin check fo make sue that anges arent expressed ina "2" ve actions In place, consider recommending a genera procedure improvement program fo remove ranges that are expressed ina" format (Once the general procedure improvement program simplemente, ‘make sure that you explin tothe procedure users why are being made and how the changes are intended performance. This may be a good tine to reinforce the actions to be procedure users ind preblems like procedures with 8 procedure so that the problems can be corected before ® References 1. To lea more about improving. procedures, attend the Day ‘TapRoot Ad idevand Practices, (993) by Douglas Wiring, ‘Ghrstopher Moore, and Valerie Barnes, publiched by Battle Pres, Columbus, Ohio 8 Checks You have decided thatthe problem was caused by @ procedire ‘eing writen at an inappropriate level of deal given the ning and experience reuired for personnel performing the work, eas Consider recommending that the procedure be rewritten at the the wrong level detail. (For example, replace the pursp” is one action that may require san father than the expe the use. Or because the previous procedure was writen at of detail, Or because the procedure details. The level of deta ‘more meaningful the reviewers should “understand the reason forthe level of deta that you have chosen for Generic Problems: you find that the level of detail in procedures sa generic problem, consider recommending additional guidance aed tain procedure writers so that they start to consider the appropri Of detall when they are wring procedures a ofa imc at 2 Consider making an evaluation ofthe evel of detail ofthe procedure a standard part f the procedure review proces, 3. Once you have trained ihe procedure writers nd modified the review proces, consider recommending 4 procedure upgrade program 0 ‘everite the current procedures a the appropriate level of Geta 4 Once the procedure upgrade programis implemented, make sure that you explain to the procure users 1. Ifyou have trouble dexrmining the appropiate level of deta! for © procedure, you should consider learning more about procedure wnting. We recommend attending the S-Day TapRooT® Advanced Root Cause Analysis Te Leader Training, For more information ca (625) 530.2138, 2 Procure Weitn: Princes and Practices, (199) by Douglas Wieringa, Christopher Moore anc Valerie Barnes, published by Battelle Pres, Columbus, Ohio, ‘Check: You have decided! tat the problem was caused by a mistake in recording or transering data of becaiseof incorrect calclations eas Consider recommending ways to make the calculation oF date collection more accurate complete, and prec, Consider recommending a second check for any critical calculations (People are notercusly bad at even the simples addition and subtraction. f you doubt this, how many times have you made book?) racy, completeness, and precision of fue: 8 Providing space to write down the numbers in a formatted caleulation, For ot head perform the math independently performed by two als and compared bya third individ, aren em e Ideas for Generic Problems 1. IF you fn that date cot probe then you showld conser changing the way the work performed (using the guidance above) and developing guidance fhe procedure wes that hey provide adequate room to perform faleulatons and require independent calulations and comparisons of the independent caelations. 2 Once these changes have been made, you can then consider recommending a everal proce ort 3 Once the proceduse improvement program is implemented, fue that you explain Io the procedure users why the changes are being made and Row the changes help performance 4A. This may be a good time to reaforce the actions to be taken f the procedure uses find problems (Uke inadequate foom to perform sin a yrocedure so that the problems can be corected before an incident ecu. References: 1p eam more atout improving procedures, attend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training For mare information ell (865) 539.219, or ee wrwtaproot.com/ pes ond Prats, (1999) by Douglas Wietings, 1 Valerie Barnes published by Batlle res, ‘Check: You have decided that the problem was related to unclear ‘Confusing oF misleading graphs, ilustrations, one-line diagrams, or System drewings ene procedure 1. Consider recommending ways to make the graphics clearer, less confusing oF les misleading, 5 ofetaconsinpamtpue ce 2. Ideas for improving graphics include: ‘Use vera ines between columns unless there plenty of space = Align column headers exactly with columns Separate column headers fom column type or both, Use groups of five lines o by using bold with margins between them to let the eye 4." Copying "Don't educe things more than 50% or tothe pont that type will be - Always stat with an original or fst generation copy t produce ' procedure. Starting witha copy of a copy of copy ts bound to rodace poor els. |deas for Generic Problem: 1 IF you find that poor graphics are » generic problems. you shoul pi tape ” 3. Once the graphics improvement program is implemented, make sure that you explain to the procedure wsers why the chang made and how the changes References: 1 To len more about improving ‘TapRooTe@ Advanced Root For more information ca ‘courses php, a Prats, (1999) by Douglas Weringa, Valerie Barnes, published by Batlle Press, because each separate ation did thatthe procedure be ewriten with a checkotfspace aftereach action tp. An examples provided below pace Pe 4 Close the acid tank outlet valve (251) ‘CAUTION Inthe next step ling the tank 050 gallons should taken longer ‘han 10 minutes. Filling times longer than 10 minutes indiate ing the tank wile you find the ease of the ‘hat you started ling the tank, Ideas for Generic Problems: 1 Ifa lackof checkof spaces isa generic problem, consider developing ‘guidance for including checkolf spaces in procedures, 2 eet ener se 2 Procedure writer should consider including checkoff spaces in procedures that are conples, have extensive valve line Significant rik if steps omited, or need documentation tat each ‘Step was performed, (Once guidance for procedure writers is in place, be sure to tain the procedure wits onthe guidan procedure users and thir supervisors the how the checkof is designed to improve performance and the proper way 10 use the check 5. Youshouldalsoconsider'aving supervisory observations procedures bing used to make sure that chacoffs are being aed covery. References 1. Tolearmmore aboutimproving procedure, atend the 5-Day TapRoot® ‘Advanced Root Cause Analysis Team Lender Training. For more Information cal (85) 535-2139, or see worwtaproot.com /eourses php. Practices, (1995) by Douglas Wierinen. ‘Barnes, published by Battelle Press Columbus, Ohio. (Check: You have decided thatthe problem was caused by acheckof being misused eas: 1. You should consider recommending corective actions to ensure that procedure users prope ons? This deer 4. Close the acd tank ote valve (V2), z i : 3 : i i the procedure user whe check is ‘the proper way to use the the! cise, consider recommending taining about the reason forthe checkots hw the checkot is design to improve performance, andthe proper way to use the checkot 4 should consider having supervisory cbervatinsof procedures "used to make sure that checks are being used correctly. 3. Also, the procedure should clesly call out the need fora secord ‘check, An example ofa ood checkof i provided below: Positioner Second Checker| 7. CloseSturry ute Valve shut the Slurry Dump ‘ou finda root cause in that category, consider the corrective actions Tisted there to improve the use of checks 44 The checkolf might have been misused because the procedure user lide’ understand the reason forthe second check: How the secre \deas for Generic Problems: problem, consider implementing joveona departmental erste-wide 2. Also, consider instituting menagement/supervsor audits of procedure usage to verify that checkos are being used correc having supervisory /managemest beng performed to make sure that thy References: performed corel. reason forte secon check how the second chek is designed o spove performance and the proper way to perform a second check were well undestoed, but the second check sil wasn't performed rectly you shoal ‘Tolean more about improving procedures att ‘Advanced Root Cause Anaya Team Leader Information call 65) 539-2139, o see wwrtaproot 2 Procure Writing: Principles nd Practices (1959) by Douglas Wi Christopher Moore, and Valerie Barnes, published by Battle Press, Columbus, ie, ener problem, consider Suggested above on a 2 Also, consider management / supervisory audits ofthe performance ‘of second checksto ensure they ate being performed corey. rinipls and Prats, (199) by Douglas Wiring Christopher Mote, and Valerie Barnes, published by Battelle Ps, Columbus, Ohio. « ‘WAG hn Oe cig pre nme a ‘Check You have found that the problem was caused by a procedure that Feview process to include a specific review fr clarity and specific. 2 Once you have trained the procedure writers and e ‘ther ambiguity problems 3. Once the ambiguous instractons have been clarified and checked, make sure that ou explain the changes to the se 4. This may be 2 good time to reinforce the actions to be taken if procedure user finds a problem (ike an ambiguous instruction) in 2 procedure so thatthe problem can he corrected before an incident References: 2 Procedure Whitin: Prnipls and Practices, (1988) by Douglas Wernga, ‘Chstopher Moore, and Valerie Bares, published by Battle Pres, Columbus, Oho. ® Tare mee famine ‘Check: You have ound that the problem was caused because component/ ‘equipment identification or labeling in the Rel didnot agree wih the dentification in the procedure eae 1 Consider recommending thatthe procedure be revised to conform to {he el abeling. If the eld labeling is particularly poor and doesn the standard wser terminology for the equipment recommending that held labeling be revied end tha the procedure then be revised to match the new fil labels. 3. ltmay bea good idea 4. Ofcourse, explain any changes that are made to the users wien they ae implemented. eas for Generic Problems: 3 standard eld terminology, you should recommending systematic review othe eld and procedure terminology and revise them 2 appropriate the actions to be taken if a ts ob an equipment identification rable) ina procedure so thatthe problems an be corected before Sn incident octurs, Reference: omnes um ones ne * LEVELS 3-5: Training ‘Check: You have decided that te problem was related to rining, eas: 1. You should continue to analyze the cause of this problem to fin the oot cause ofthe training problem. You can thes correct the foot 3. If pat ofthe problem you are having in analyzing the taining 3 lack of oF incomplete or inaccurate Waining records then you should ‘proving the traning records 50 that iy tracked, people missing taining can be ealning oF retaining can be scheduled 44 Decaf that you do’ try to se taining to fx evry problem. For ‘example, you should not expect that all probleme er poorly hima factored designs can be reliably overcome by providing extensive consider resmnmendh 6. Also, you may wantto consider the supervisorsroleand the nes for beter proj bres or wall-thras before the performing the typeof work involved in hs problem, 7. Also, i you implement an improvement to the tiring, you should ‘onside? how the people who have already been tained will be ‘trained References: 1 For more information about the theory behind the systematic approach to trainingand developing effective training we recommend attending the5 Day TapRooT Advanced Root Cause Analysis Team Leader Training For more information about the course al (65) 39" 2139, or eee wnrntaprootcom/courses hp. = ‘efsTocomc ont 1 You should continue to analyze this problem to determine the root ‘cause forth ack of aig 2 Hyowca 8-304 should sti consi etn forthe 3. Before asinga weaker safeguard such a a 7 you should additionally consider using the Safeguards hlcarly, by removing the hazard, removing the target from the hezandos situation, or guarding the person or target from the asses ess for Gener: Problems: ltyou find tha the lack of waning is more widespread you should consider recommending. effective training forall the workers Who nto prevent future problems. em with taining that theres her important tasks beyond the one svete in this problem, you should consider recommending a taining improvement rogram that would start witha taining needs analyse and a forse ‘eis aout which topics ned tobe include inthe ann program, getfectve taining, attending the5-Day TapRooT® Advanced Root Cats Leader p84 Sempra ® SEL I requirements OF Knowledge necessary t@ succsaflly perform those asks) Ideas 1 analysis are more complete nce you have identified workers, you will need Ina waining program to provide the raining that nw workers nee ‘Wie Oem ining. For more information about the tai 599-2138, or see www aproo.com/ courses php ‘Melted, Resear, and Applictons for Human 2007, by lorpeson, pul (Check: You have found thet there was 3 canscious decison not to train ‘ope on the task thateaused this problem. Ideas aused hls problem. work is infrequently performed, you should also consider recommending that 2 prejob brief of ‘wallthrough should be performed before string the work eas for Generic Problems 1 Ifyou find that deciding not tain peoples a generic problem then ze why snot assigned to you and the taining third party, consider auditing yout contractor training requirements and status o improve Management System isuee, Once you have Kentifie all the additional tnning needed by the ‘workers, implement a taining program to provide adliinal traning p15 pen gen « tothe already qualified workers and revise dheinital-aining program to provide the training that new workers nee. References! 1. For more information about the ery behind the systematic Spproach to tainingond developing efetive training, we ‘htending the 5-Day TapRooT® Advanced Root Cause Analysis Team faining, For more information about the course call 865) 539- see wwrvlaprootcom/ courses php 2 Trang Onions: Nels, Assman Dlg “rnd Edition (19%) by Irwin Goldsten, published by ‘rook/Cole Pblshing Company, Pcie Grove, CA tnt of efetive he probe, ‘deat for Genere Problems: a Tack of learing objctives f a gnere problem, {ny to find out why the leaning odetves were nol hat were supposed to be inca inthe taling already qualified provide the taining that nee workers need 2138, or see wrctaproot com curses pp. ® ‘ys cana pt te ‘Check: You ave decided that the problem occurred because there wa twining because the worker didnot attend required training onsider recommending required taining. You should consider chee 2 required tearing they be generic problem and you should consider the suggestions under the dens or ene Problems. ining records are not complete enough to determine i people tended requied taining you should consider recommending improvements othe raining records stem. ‘reblems with the taining sched rabies with student notification king recording, and racking attendance (esining sms with the taining requirement policy also conser the gement System -SPACNT SSSSSTITIT fener) testing to sce thatthe skill was acquired. 3. Also, you should consider recommending the development performed, you find that understanding of talning is ge should consider recommending a thorough au rogram to find the underlying causes af the prog 2 Once you have identified and corrected all the pr the training. program, you should consider recommending a re eployment of the waining program that includes development 0 ‘ew taining modules, ole Publishing Company, Pcie Grove, CA. 3. ANSI/ASSE 4901-2009 Citra or Accepted rl 1 Encranmentd Tring Satya, ” Tost Coma cn ‘Check: You have decid thatthe problem occured because the writen eaming objectives in he lesson plans failed to ensure thatthe raining Provided the knowiedgeor skill needed to perform the task. Ideas: 1. You should consider recommending an appropriate laming objective ‘hat taining be developed fr curent and future werkars to ensure they develop the skis and knowledge required to perform the task, ijoctives should be “performance based” 30 ‘demonstrate (perform) the knowledge, sk ire. su decide that poor learning objectives a ld ty to determine why the poo la oped and fx the generic problem, Once you have fixed the generic problem th generic problem, you ng objectives are being, 3 should ao evaluate the training traning program and recommend rere 4 Ofcourse hentia traning program will nee tobe revised to include ‘he newly developed learing objectives and raining modules References 1. For more information about the thoory hind the systems approach totraining ad devel istein, pul Brooks/Cole Publishing Company, Paci Grove, CA Check: You have decided that the prablem was caused by lesson plans that did't ensure effective taining opr 25 Sm et 6 nding NI) n Trainin Hess Yous come commen hereof een an 0 ‘ problem is corrected. This could include: Ideas for Generi Problems 2. you find that inadequate ‘ced to determine why References 1. For more information about the theory behind the systematic approach otainingand developing effective Brooks /Cole Publishing Compa ‘Check: You have decided thatthe problem was causee by inadequate ‘retentaton ofthe taining. Pact Grove, CA 1 You should consider recommending that the inetrctonl techniques bbeimproved to provide adequate ining. “ “at connec 2 If the instruction was ot given inthe native language of the user,

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