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TapRooT Brief
TapRooT Brief
TapRooT Presentation
HUMAN E NGINEERING
Pa g es 93 -1 1 2
Hu m a n - M a c h in e
Inte rfa c e
l ab e ls NI
W o rk
En v iro nm en t
Co m p le x
Sy s tem
k n owl ed ge -
arran ge m e n t/
pl a c e m en t
ho us e k ee p i ng
NI
ho t/c o ld
di s pl ay s NI
we t/s l i c k
c o ntrol s NI
m o ni tori ng
al e rtn es s NI
li g hts NI
m o ni tori ng t oo
m a ny i tem s
pl a nt/un it
di ffere nc e s
ob s tru c tio n
ex c e s s i v e
li fti ng
eq ui p m en t gu ard NI
ba s e d d ec is i o n
re q ui red
No n -Fau l t
Tol era nt Sy s te m
e rro rs n ot
d ete c ta bl e
e rro rs n ot
rec o v e rab l e
no i s y
c ra m p ed qu arters
hi g h rad ia ti on /c o nta m i na ti on
TapRooT
Use technique called SnapCharT
To understand what happened and how it
happened.
Use TapRooT Root Cause Tree
To use systematic process to find each
problem's root causes.
SMARTER Corrective Actions and Corrective
Actions Helper
To develop effective fixes
Determine
Sequence of
Events
(SnapCharT)
Define
Causal Factors
Analyze Each
Causal Factor's
Root Causes
(Root Cause
Tree)
Analyze Each
Root Caus's
Generic Cause
(Root Cause
Tree)
Develop &
Evaluate
Corrective
Actions
(SMARTER)
Report and
Implement Corrective
Actions
(DoD RCA Form)
SnapCharT
Condemnationwithoutinvestigationistheheightofignorance.
AlbertEinstein
Person walks
to car
Incident
Person
sprains
ankle
Person steps
in pothole
Parking lot
light out
Transported
to hospital
& treated
Amplifying information.
Explains event.
No barricades
around hole
Pothole reported
4 weeks ago no action taken
Used to:
Systematically guide team to the root causes of human
performance & equipment problems
Focus on finding fixable causes rather than on placing blame
Provide common language for discussions & trending
Not Used /
Not Followed
no procedure
procedure
not av ailable or
inconv enient
f or use
procedure
dif f icult to use
procedure use
not required
but should be
Wrong
ty po
sequence wrong
f acts wrong
situation not
cov ered
wrong rev ision
used
second checker
needed
Followed Incorrectly
f ormat conf using
> 1 action / step
excess ref erences
mult unit ref erences
limits NI
details NI
data/computations
wrong or incomplete
graphics NI
no checkof f
checkof f misused
misused second check
ambiguous instructions
equip identif ication NI
Develop SnapCharT
Get Started
- Determine what you are investigating
Define sequence of events
- Identify missing or needed
information
- Investigate further to find missing
information
Define causal factors
Copyright 2000 by System Improvements Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
Corrective Actions
S pecific
M easurable
A ccountable person
R easonable
T imely
E ffectiveness review
R eview for unintended consequences
START
HERE
Off-Site
Incident
Other
Facilities
Evaluate & Decide
on Implementation
Immediate Fixes
No
Document
Decision
Document
Yes
Document/
Track/
Validate
Re-Analyze &
Develop New
Corrective
Actions
Implement Fixes
Investigation
Measure
Effectiveness
Long Term
Corrective
Actions
Recommended
TEST
Effective
Done
Re-Analyze &
Develop New
Corrective
Actions
Fixes
Implemented
Doesn't Work
TEST
Document/
Track/
Validate
Measure
Effectiveness
Effective
Doesn't
Work
QUESTIONS?
Hu m an - M a c hi n e
In te rfac e
la b e l s NI
W ork
En v i ron m e n t
Co m pl e x
Sy s tem
ho u s ek ee p i n g
NI
ho t/c ol d
k no wl ed g e-
a rra ng e m e n t/
p l a c e m en t
d i s pl a y s NI
we t/s l i c k
c o n tro l s NI
m o ni to rin g
a l e rtn e s s NI
li g h ts NI
m on i tori n g to o
m an y i te m s
p l a nt/u ni t
d i ffere n c e s
ob s truc tio n
e x c es s iv e
l i fti ng
eq u i pm en t g u a rd NI
to o l s /i n s tru m e n ts NI
b as e d d e c i s i o n
re qu i red
no i s y
c ra m pe d q u a rte rs
hi g h ra d ia ti o n /c on ta m i n a ti o n
Non -Fa u l t
To l e ra n t Sy s tem
e rro rs n ot
d e tec ta bl e
e rro rs n ot
re c ov e rab l e