TapRoot 1 Day - Condensed

TapRooT ®
1 Day Course
The Investigation
SnapCharT®
1 Get Started
Root Cause Tree®
What?
2
Determine
SnapCharT®
Major
Sequence of Events
Techniques
Define (Use every time)
3 Causal Factors Safeguards
Analyze Each Causal

Why? 4 Factor’s Root Causes
Root Cause Tree®
Corrective Action Helper®

Optional
Analyze Each Root
5 Cause’s Generic Cause Root Cause Tree®
Techniques
(Use when needed)
Develop & Evaluate SMARTER
6 Corrective Actions
Safeguards
Fix?
Report & Implement SnapCharT® Software
7 Corrective Actions Root Cause Tree® Software
Step 1 – Get Started
Using SnapCharT® to Plan Your Investigation
Another Employee
Employee Employee Employee Transported to
walks to steps in Sprains Employee
Notifies Emergency Room
car Pothole Ankle & Treated &
Security
Released
What key pieces of Who needs to be interviewed?

evidence need to be
collected and preserved? Have initial observation forms
been filled out?
What procedures/policies
were used (or should
What key facts or event have been used) during
times need to be verified? the incident?
Step 2 – Determine the Sequence
Another Employee
Security
Released
Get Information:
• Lights Out for About 3 Days
• Parking Lot Lights Burned Out
• Employee Left Work After Dark
• No Work Order For Lights in the System
• Pothole about 4” Deep
• Pothole Reported 4 Weeks Ago
• Pothole Repair Work Order Submitted – No Action Taken
Step 2 – Determine the Sequence
Add Conditions to the Sequence
Another Employee
Security
Released
Hole
After Dark
4”
Deep
Lights Out Reported 4

Conditions
weeks ago
Conditions
3 Days? Work
order
submitted Amplifying Info about
No work No action an event
order taken
submitted What? & Why?
Building a SnapCharT®
Start by defining the INCIDENT

The incident is the reason for the investigation.
INCIDENT
It may be the worst thing that happened.

The incident defines the scope of the investigation.
Build the SEQUENCE OF EVENTS
Method #1
Build START to FINISH
(Reviewing Reports)
Method #2
Build FINISH to START
(A significant failure that just occurred)
Method #3
FILL – IN – THE – BLANKS
(Typical method)
Draw Events First
Date/Time
What
Who Did Who Did Equipment Who Did What
What? What? Incident After the Incident?
Did What?
(Dashed box or oval = assumption … not yet proven fact)
Events are actions – use active verbs
Only one action per box
Sequence in chronological order (real time)
Use job titles/functions instead of names to reduce a blame focus

Add Conditions
What do I know about each Event?
Was there anything about this Event that was different than desired?
What Who Did What

Who Did Who Did
Equipment Incident After the Incident?
What? What?
Did What?
}
After Dark
}
Different After Dark After Dark
More Info Lights Out Lights Out Lights Out
If independent
If related
– in parallel
– in series
More About Conditions
Conditions help to explain each event
by asking:
¤ How ¤ Why
¤ What ¤ To What Extent
¤ Where ¤ Under What Conditions
Use passive verbs Clarifying facts/data –

such as be, is, was, quantified if possible
has been…
How actions or
Conditions should NOT equipment response
include action steps was different than
desired?
SnapCharT® Guidelines
Summary
Events: Conditions:
“Who does What” Tells what we know about an Event
OR How / What / Where / Why / To What
“What does What” Extent / Under What Conditions
One Action Per Event Who did what wrong?
Sequence from Left to Right What equipment failed and how did it fail?
Include Dates / Times What was different from desired?
11/10/2006 12:45 PM
Conditions should NOT include action steps
Use job titles/functions instead of names

ALL items on chart should be: If Assumption/Unverified Fact:
- Factual
- Dashed Box
- Non-Judgmental
- Precise & Quantified - Dashed Oval

Investigation Seasons
Spring Get Started: What do I know? What information
do I need to collect?
SnapCharT®
(It’s your Planning Chart)
Summer Complete sequence and ALL conditions

SnapCharT® (It’s your Working Chart)
Prune unnecessary information. Reorganize. Define

Autumn “Causal Factors”
SnapCharT® (It’s your chart to define causal factors for root
cause analysis)
Cut to only what’s needed to understand causal

Winter factors & root causes.
SnapCharT® (It’s your Management Presentation Chart)
Spring Chart Sample
What happened before the
nurse applied the What do I know?
ointment?
Obtain Doctor’s
prescription for What information do I need?
patient
Look at nurse’s work

schedule (human
factors?)
Spouse picks up and Nurse enters

Nurse performs Patient
applies nitroglycerin room, realizes
1st of two daily Nurse paged to becomes Patient put under
Patient's spouse ointment to patient's what has
Nitroglycerin attend to another flushed and 24 hour
comes to visit dentures & inserts happened and
ointment patient dizzy with surveillance
dentures into patient's immediately
applications headache
mouth removes dentures
Interview spouse
Obtain copy of hospital policies &

procedures pertaining to
administration of medication
Summer Chart Sample
4/7/1996 8:30 AM 9:10 AM
Nurse enters Nurse performs
Nurse retrieves Nurse moves to
patient's room and 1st of two daily Nurse paged to
Nitroglycerin ointment computer terminal to A
checks computer Nitroglycerin attend to another
from medicine input treatment
station for care ointment patient
cabinet information
information applications
Nitroglycerin ointment
Followed treatment
Ointment is applied twice is left at patient's
prescribed by Used as a second check bedside
daily to chest by nursing staff
primary physician vs. the patient chart
for patient's heart condition
Ointment container
contains ten Hospital policy states that all
treatments medications should be in the
custody of the nurse or physician
Nurse was at the end
of the shift
Has been working

double shifts for
previous four weeks
9:20 AM 10:15 AM
Patient
Nurse finishes becomes Patient put under
A Patient's spouse ointment to patient's what has
data entry and flushed and 24 hour
leaves room dizzy with surveillance
headache
No check of patient's room Spouse believes the

for medications or hazards ointment is denture cream
Patient requires close
monitoring due to
ingestion of ointment
The tube containing ointment

doesn't have readily identifiable
markings to indicate the contents
Exercise: Draw a SnapCharT®
1. Read the preliminary report.

2. Use information to draw a Summer
SnapCharT®.
REMEMBER:
Work on “Sequence of Events” first.
(Who Did What? Or What Did What?)

Then add Conditions,
Questions, & Assumptions
Hazardous Spray Exercise
Initial Conditions: Thursday, January 3, Supervisor. He gave them permission to The Unit Operator notified the Shift
2006, 10:35 AM. Normal plant operations. install the new A2 detector and told them to Supervisor of the problem who had the two
Removal and replacement of Line “A” inform the Unit Operator about the pipefitters report to the site first-aid station.
pressure detector number 2 was in progress. replacement. The pipefitters were referred to the county
hospital where they were observed overnight
Description of Incident: Two pressure They then went to the unit, found the Unit and released the next morning.
detectors (to provide a redundant capacity) Operator (making hourly reading checks)
are available on each of three feed inlet and informed him that they were there to Both pipefitters were wearing safety glasses
lines. Pressure detector number 2 on Line replace detector A2. The Unit Operator said but no full face shields nor protective gloves
“A” failed low at 11:15 PM on Wednesday that he told them the off-going shift had as required by MSDS. One received first
(08/06). Maintenance and Operations drained the system and that it was ready for degree burns to his face and hands. The
management decided to replace the detector work. The Unit Operator did not got to the other received a first degree burn to one
with a pre-calibrated spare during the day work site and review the work with the hand. Both returned to work the next day on
shift on Thursday. pipefitters (required by plant policy). a restricted work basis.
The midnight-shift Unit Operator prepared The pipefitters then went to the detector Further investigation showed that the
the work request and tagout for detector A2 platform (an elevated platform that provides detectors were not within sight of the
and had it authorized by the midnight-shift easy access to the detectors which are locked-out isolation valves (isolation valves
Shift Supervisor. The midnight-shift Unit approximately 10 feet above floor level) and were at floor level underneath the platform),
Operator says that on Thursday, at about began to loosen the detector’s connecting there were no equipment identification
6:30 AM, she isolated detector A2, drained flange bolts. They did not hang their own labels on the detectors, and the senior
the hazardous fluid into an approved locks or tags on the isolation valves or trace pipefitter, who was familiar with this type of
container, and placed appropriate isolation the lines (required by plant policy). When unit, said he thought he was disconnecting
tags and locks on the A2 isolation valves. the third bolt was about three turns loose detector A2 because he believed the detector
She then called the Shift Supervisor and (they had already removed two of four arrangement was the same as the “identical
informed him that detector A2 was ready for bolts), hazardous material began spraying units” he was used to working on. However,
removal and replacement. from the flange onto the pipefitters. They he disconnected A1 instead of A2 because
retightened the third bolt, but the spray the arrangement is backward to the other
At 8:00 AM shift turnover occurred. The continued until one of the previously “identical units”. The company’s line break
day-shift Unit Operator and Shift Supervisor removed bolts was inserted and tightened. procedure requires pipefitters to loosen all
were told detector A2 was ready for removal Overall, the spray lasted about one to two bolts and break the line away from them
and replacement. The day-shift Shift minutes. before they remove any bolts.
Supervisor contacted the Maintenance
Foreman to get the work started. The The Unit Operator, who had just come by,
Maintenance Foreman assigned two took them to a nearby eyewash and wash
pipefitters to the job. down station.
At 10:00 AM, the two pipefitters arrived at Both rinsed the fluid off their skin.
the control room and talked to the Shift
“Hazardous Spray”
Exercise
Maint. & Oper.
Mgmt. decide to Hazardous Pipefitters A & B go Pipefitters A & B
Pressure Detector material sprays to first aid station return to work next
#2 on Line A fails
replace failed
detector on ? onto and burns
Pipefitters A & B
? then county
hospital
day on restricted
work duty
Thursday day shift
TEAM LEADER:
Facilitate team exercise, make sure all members have input, and
keep team focused on goals of the exercise
RECORDER:
Record the analysis on Post-it® Notes
CHECKER:
Check format of SnapCharT® to ensure it complies with format
guidance
Autumn SnapCharT®
Define Causal Factors

SnapCharT®


cause analysis)

Step 3: Define Causal Factors
SnapCharT®
1 Get Started
Root Cause Tree®
Determine
2 SnapCharT®
Review the
Sequence of Events
information 3 Define
Causal Factors Safeguards
on the
SnapCharT® 4
Analyze Each Causal
Factor’s Root Causes
Root Cause Tree®
and identify
Causal
Analyze Each Root
Factors. Corrective Action Helper®
Safeguards

Causal Factor
A problem or issue that, if corrected,
could have prevented an incident
from occurring or significantly
reduced the incident’s
consequences.
A Quick Way to Find Causal Factors

(but not the only way)
CF CF
Who did what What equipment
wrong or what was failed or did not
done wrong? work as intended
Something that allowed the incident to occur or made it worse.

Something that should have stopped or lessened the incident.
If two or more problems relate, attach & use the most general.
Causal Factor Example
Maintenance
Post-flght inspection
Work order issued to dispatcher assigns two Mechanics go to Mechanics jack up Aircraft
identifies #4 tire for
maintenance mechanics to replace aircraft to start work aircraft Damaged
replacement
tire
mechanics have
limited experience
Cut in sidewall of on this aircraft
tire
What is the Causal Factor? mechanics
properly licensed
by FAA
mechanics did not

review and bring
Who did what wrong or what was done wrong? copy of maintenance
manual reference
required by
company policy
What equipment failed or did not work as intended?

mechanics do not position
jack under "jacking ball"
as maintenance manual
instructs
Do these two relate? If yes, which is most general?
Maintenance
replacement
tire
mechanics do not position

Cut in sidewall of jack under "jacking ball"
tire as maintenance manual
Causal Factor:
instructs
Who did what

mechanics did not
mechanics
review and bring
properly licensed
copy of maintenance
by FAA
wrong?
manual reference
mechanics have
required by
limited experience
company policy
on this aircraft
“So What?” Method
Maintenance
replacement
tire
So what resulted because mechanics mechanics do not position

Cut in sidewall of
tire
didn’t position the jack correctly? jack under "jacking ball"
as maintenance manual
instructs
Causal Factor: mechanics did not

review and bring
mechanics
Who did what

properly licensed
copy of maintenance
by FAA
manual reference
wrong? mechanics have

required by
limited experience
company policy
on this aircraft
So what resulted because mechanics

did not review the maintenance
manual before they did the job?
Only one
bracket to be
moved
Worker starts Worker leans to Worker falls

Worker climbs Nut breaks free Worker breaks
unbolting extra put extra force 10 feet to
scaffold & worker slips arm & 2 ribs
bracket on stuck nut ground
Worker in a hurry
to finish job
Worker thinks this What problems do you see?

will only take a
minute
Work plan calls What’s the Causal Factor?

for fall protection
Policy requires
fall protection Use “So What…?”
No harnesses at
job site
Fall protection
Worker does not
frequently not worn
wear fall protection
for "quick" jobs
Causal Factor Answer
Only one
bracket to be
moved
Worker starts Worker leans to Worker falls

Worker climbs Nut breaks free Worker breaks
unbolting extra put extra force 10 feet to
scaffold & worker slips arm & 2 ribs
bracket on stuck nut ground
Worker does not

wear fall protection
Who did what wrong?
Work plan calls

for fall protection If you chose this, ask “So what?”
Policy requires “So what resulted because there was
fall protection
no harness at the job site?”
No harnesses at
job site
Try to identify only 1 Causal Factor per

Worker in a hurry
to finish job Grouping
Worker thinks this Fall protection

If you identify more you may end up
will only take a frequently not worn with the same root cause
minute for "quick" jobs
Tank
overflows,
Operator hits stop
Operator leaves plant spilling 100
button
barrels of
product
What are the Appears to shut

Operator in a hurry
Causal down but flow
continues
to get home
Factors?
Operator didn't
Stop button didn't check that flow
work stops
Stop button failures Procedure requires

have happened 3 check before
times at 2 other leaving area
company plants
Causal Factor Answer
Two Causal Factors
Tank
overflows,
Operator hits stop
Operator leaves plant spilling 100
button
barrels of
product
What
equipment Stop button didn't
Operator didn't Who did what
check that flow
failed?
work
stops wrong?
Appears to shut So what Operator in a hurry

down but flow
continues resulted to get home So what
from this? resulted
Stop button failures Procedure requires from this?
have happened 3 check before
times at 2 other leaving area
company plants
Summer  Fall Snap CharT®
Employee A Employee Employee B notifies

Employee A
steps in A sprains Security who takes
walks to car
pothole ankle Employee A to ER
no funds for pothole problem Security reported

paving repair in reported 4 weeks lighting out 3 days
budget ago ago
no request for work order Step 1:

no work order
added funds for submitted by
this repair maintenance
written Group all
associated
work order in conditions
no action taken to no action taken by
repair pothole
backlog for 4
maintenance about a
weeks
problem
work order not
identified as safety
problem

Employee A
walks to car
no funds for pothole problem Security reported

paving repair in reported 4 weeks lighting out 3 days
budget ago ago
no request for work order

no work order
added funds for submitted by
written
this repair maintenance
work order in
no action taken to
repair pothole
backlog for 4
no action taken by
maintenance
Step 2:
weeks
Define a
work order not
Causal
identified as safety Factor for
problem
each group
A More Detailed Approach to Find Causal Factors

1. Group associated information about a problem on your SnapCharT®.
2. Identify all of the problems on your chart.
3. For each group, pick a problem and ask yourself, “So what resulted
because of that problem?” Then ask, “So what resulted from that?...So
what resulted from that?”…etc. until your answer is, “The incident
resulted from that.”
4. One back from the circle will be the causal factor unless there are several
policies involved in that causal factor, then you may need to go back
more than one level of “So what..?” questions to pick a causal factor that
involves only one policy.
The most general problem is usually some task that was done improperly
or was not done or equipment did not operate as it was intended to
operate.
5. If needed, rewrite the condition so that a problem is clear & concise.
6. Place a Causal Factor symbol (triangle) on the most general condition
and arrange the related conditions under it to clearly tell the story.
Employee A
walks to car
Maintenance did
Maintenance did
not repair parking
not repair pothole
lot lights
pothole problem Security reported

reported 4 weeks lighting out 3 days
Rewrite
ago ago
work order conditions if

no work order
submitted by
maintenance
written needed for
clarification
work order not work order in
identified as safety backlog for 4
problem weeks
no request for no funds for

added funds for paving repair in
this repair budget
Why Define Causal Factors?
Smaller Chunks of Information

Cut the incident into smaller more
manageable pieces of information so you
don’t have more than one policy or procedure
to remember when you ask questions from
the Root Cause Tree®.
e.g. “Were policies, admin. controls, or

procedures not used, missing, or in need of
improvement?”
Why Define Causal Factors?
Reduce Biases
If you are operations, who causes problems?
If you are maintenance, who causes problems?
If you are management, who causes problems?
If you are workers, who causes problems?
Using Multi-disciplined teams (or interviewees) to

define Causal Factors allows everyone to identify
areas where there are problems. This makes it
more likely that we will find and fix all problems.
15 Minute Exercise
Conditions Conditions
On your
Conditions
SnapCharT®
Identify Causal
Factors From
This Morning’s
Exercise
Causal
Factor
Hazardous Spray
SnapCharT®
8:30 AM
1/2/2006 11:45 PM 1/3/2006 1:51 AM 6:30 AM 6:45 AM
Shift Supervisor
Maint. & Oper. Mgmt. Operator isolates Shift supervisor turns
Operator tells Shift calls Maintenance Shift Supervisor sends
decide to replace Operator prepares detector, drains fluids, over to next shift that A
Supervisor detector is Foreman who Pipefitters A & B to
failed detector on work request hangs tags on detector ready for
ready for work assigns Pipefitters Operator A
Thursday day shift isolation valves work
A&B
Detector failed
Wednesday Note: LO/TO may involve 20 steps but if it was
evening
done correctly you can use just 1 summary step
Pipefitters remove in your autumn and winter charts
Why did it fail? Is
bolts instead of
this a frequent
loosening bolts first
problem?
(good practice)
Pipefitters A & B Pipefitters A & B Operator A directs

Hazardous
Pipefitters A & B talk Pipefitters A & B remove 2 bolts retighten bolt & Pipefitters to
A material sprays B
to Operator A who disconnect and loosen third insert & tighten washdown station
onto Pipefitters
says detector is ready detector bolt on detector 2nd bolt to stop and notifies Shift
A&B
flange spray Supervisor
Pipefitters in spray
Operator A does not go approximately 2
Pipefitters wear safety minutes
to job site with Pipefitters
glasses but not full
to review work (required
face shields or gloves
by plant policy)
What is policy for
"See and Flee"?
Did Pipefitters
Pipefitters go to
review MSDS /
work without
safety requirements?
Operator
Pipefitter A
disconnects A1 (thinks Pipefitters A & B Pipefitters A & B
Pipefitters do not do
he is disconnecting A2) B go to first aid return to work next
lockout / tagout
station then day on restricted
(required by plant
county hospital wok duty
policy)
No labels on detector
Pipefitters do Pipefitter A thinks detector Pipefitters receive

not trace lines Detectors on platform
arrangement is same as first degree burns on
10' off floor and not
another unit that he's face & hands
near isolation valves
familiar with
“Experience is not what happens to a
man. It’s what a man does with what
happens to him.”
~Aldous Huxley
Step 4: Find Root Causes
SnapCharT® Use the Root

1 Get Started
Root Cause Tree® Cause Tree®
to
Determine
2 Sequence of Events
SnapCharT® systematically
analyze the
Define components of
3 Safeguards a work system
Analyze Causal Factors
EACH
Analyze Each Causal
Causal Factor 4 Factor’s Root Causes
Root Cause Tree®
to find
Root Causes Analyze Each Root Corrective Action Helper® Goal is to
5 Cause’s Generic Cause Root Cause Tree® identify root
Corrective Action Helper® causes, or
Develop & Evaluate
SMARTER sometimes
Safeguards
called SPECIFIC
Report & Implement SnapCharT® Software Root Causes
Every
Category
Is
Defined
Yes = select a category

No = eliminate category
Start Here
Causal Factor: Pipefitters do not do lockout / tagout
(required by plant policy)
Work Top Left

to Bottom Right
Only Work ONE Causal Factor at a Time!!! Use Process of
Elimination
15 Questions
Answer all
15 Questions
as they
relate to the
selected
Causal
Factor NOW, anything circled
takes you to the “Basic
Cause Categories” on
Circle “Yes” the BACK Side of the
Root Cause Tree®
Cross Off “No”

The 15 Questions:
1. Lead you to the
checked Basic Cause
Categories (BCC)
2. Eliminate whole
BCC’s, making the
process efficient
Any checked BCC must

be evaluated for
POTENTIAL
Root Causes
Basic Cause Category
Terminology
Near Basic Cause Category
Root
Causes
Root Causes
{
Root Causes are things
you can fix
NI = Needs Improvement
May also substitute LTA (Less Than Adequate) or PIO (Potential Improvement Opportunity)
“Root Cause” Definition
The most basic cause (or causes) that

can reasonably be identified that
management has control to fix and,
when fixed, will prevent (or significantly
reduce the likelihood or consequences
of) the problem’s recurrence.
Step 5: Find Generic Causes
SnapCharT®
1 Get Started
Root Cause Tree®
Fixing Generic Causes
Determine
SnapCharT® will prevent future
incidents with the same
Define root causes from occurring
Analyze Each Causal

4 Factor’s Root Causes
Root Cause Tree®
Analyze Each Root Generic Cause = Systemic Cause

5 Cause’s Generic Cause Root Cause Tree® that allows the
root cause to exist
Safeguards

From Specific to Generic
Specific Cause:
Equipment Difficulty
- Equipment/Parts Defective
- Storage
(Equipment corroded due to storage outside
without adequate protection)
Presence of water, moisture or

Generic Questions: corrosive substances in the bearing
over a long period of time.
Was other machinery stored this way?
Has it been checked?
Do we have a systematic way to prevent this?
If we did, why didn’t it work?
From Specific to Generic
Root Cause is: PROCEDURES – Wrong - typo
1. Ask: “Do we have any more of these?” Procedures? YES

2. If the answer is yes, ask:
“Do a significant number of _________________
Procedures
have similar problems?” YES (typos)
3. If the answer is yes, ask:
“What in the system (Procedure writing system)
is allowing ________________________
Procedures with typos to exist?”
Example of a Generic Cause
Root Cause
(Specific Cause):
PROCEDURES –
Wrong - typo
Generic Cause:
We have no
proofing/checking
system for our
procedures.
“We ought not to look back unless it is to
derive useful lessons from past errors,
and for the purpose of profiting by dear-
bought experience.”
~George Washington
Step 6: Develop
Corrective Actions
SnapCharT®
1 Get Started
Root Cause Tree®
Determine
SnapCharT®
Define
Analyze Each Causal

Root Cause Tree®
Analyze Each Root


Safeguards

Three Standard
Corrective Actions
“Survey Says:”
Discipline Training
This is
Procedures “The BOX”
for many
people
Get “Outside the Box”
Use Corrective Action Helper® Module
1. Verify the root cause(s).

2. Remind people to check for
Generic Causes.
3. Get “Experts” to develop
“Outside the Box” ideas for
corrective actions for every
category on the Root Cause
Tree® (specific & generic).
4. Provide references for those
who want to “dig deeper.”
Click The CA? button then

click the root cause to
launch the Corrective
Action Helper®.
SMARTER
Corrective Actions
Specific
Measurable
Accountable
Reasonable
Timely
Effective
Reviewed
Specific
What exactly is to be done?
Are the expectations clear?
What assistance should be provided for the corrective

action?
Example – what procedures, policies, tools, PPE, etc.
Under what conditions should the corrective action be

done?
Example – shut down, LO/TO
Measurable
Does the corrective action have a method/checkpoint to determine:

- If it has been implemented as desired.
- Can the effectiveness of the action be measured?
Examples – After implementation, have checkpoint to:

Measure implementation by going to field and see if label was installed.
Measure effectiveness by having user identify proper equipment using label.
Measure implementation by checking training attendance via training records
Measure effectiveness by tests, job observations, interviews, etc. after
training has been conducted to ensure learning.
Accountable
Do the responsible people agree on the corrective action plan

and implementation?
- Has the responsible person agreed to the due date?
- Did the responsible person help develop or agree to the action plan?
Do the right people know it is their responsibility to implement

the corrective actions?
Reasonable
Does the Corrective Action make good business sense?
Has a Return-On-Investment been calculated?
Has a cost/benefit ratio been developed?

Timely
Should we keep the facilities, process, etc., shut down until the
corrective action is implemented?
Has a due date been set that will allow sufficient time for the
corrective action to be implemented correctly?
Has due date been set so far out that it is unreasonable?
Have milestones / checkpoints, been established for corrective

actions that may require longer implementation periods?
If implementation will take a long time (e.g. capital project),

do you have an interim compensatory corrective action?
Effective
Will the corrective action fix the specific root cause?
- Actions for better enforcement of the policy or work rule?
- Actions to ensure that adequate pre-job briefings occur?
Will the corrective action address generic problems?

- Are there other policies that need better enforcement?
- Are there other areas where pre-job briefings need to be evaluated?
Do you have a check point in your corrective action to be sure that it

really fixed the problem that you attempted to fix?
Reviewed for
Unintended Consequences
Has the corrective action been reviewed for unintended

consequences? (prior to implementation)
– Reviewed by someone independent
– Reviewed by user in the field
– Does fixing the problem create another problem that may be
even bigger than this problem? (e.g. airbags reduced head
injuries but caused death from explosions to children and small
adults)
– Will the corrective action require a different approach to the
way or the method that work is accomplished? (more pre-
planning, more restrictive PPE, more supervision, more time to
finish)
Safeguards Analysis
Concept
SnapCharT®
1 Get Started
Root Cause Tree® Safeguards Analysis is
a tool to help collect
2
Determine
SnapCharT® information and help
Sequence of Events
define causal factors
Define
It also may be used
proactively to identify
4
Analyze Each Causal
Root Cause Tree® weaknesses in the
Factor’s Root Causes
control of hazards
Analyze Each Root
5 Cause’s Generic Cause Root Cause Tree® It can be used to
evaluate new
Develop & Evaluate
SMARTER
corrective actions or to
Safeguards
develop corrective
Report & Implement SnapCharT® Software actions if you can’t find
7 Corrective Actions Root Cause Tree® Software root causes
Safeguard Categories
Physical safeguards: walls, electrical insulation, shut valves…
Natural safeguards: distance, time, laws of nature….
Human actions as safeguards: monitoring critical parameters,

manually controlling process…
Administrative controls as safeguards: tag out procedure,

pre-flight checklist, warning signage…. Quasi-Safeguards are used
to improve or cause human
action, which is the real
Admin Controls are trying to make a
Safeguard
Human Action occur a certain way
All Safeguards
Are Not Created Equal
STRONGEST
1. REMOVE / REDUCE THE HAZARD
2. REMOVE THE TARGET
3. GUARD THE TARGET
4. RULES, SIGNS, PROCEDURES
5. TRAINING, SUPERVISION, SELECTION
WEAKEST #4 & #5 are not pure Safeguards…

Instead, they influence / cause human action
which is the real Safeguard
Safeguards Example
What safeguards would we need if we chose to have a live tiger as
our airline’s mascot?
Physical Safeguard Natural Safeguard
Put the tiger in a caged area Provide some open space around the cage
so the tiger can’t thrust his paw through
the bars and claw a passerby
Erect a fence between the open space and
the sidewalk running by the tiger’s caged
area to keep people out of the open space
Human Action Safeguard Administrative Control Safeguard
Station a guard around the fence to keep Post warning signs (for the people, not the
people away or install remote cameras tiger)
which are monitored by a guard
Train the tiger not to hurt people
Multiple Safeguards
= Defense in Depth
Multiple Safeguards
= Defense in Depth
Training & Qualification
Verification Communication Practices
Policies & Procedures Work Control & Organization
TASK
FAILURE
Safeguards Analysis
(Reactive)
SnapCharT®
1 Get Started
Root Cause Tree® Defining Causal Factors:
Identify (with red walls) the
Determine failed safeguards
SnapCharT®
Define
3 Causal Factors Safeguards Evaluating Corrective
Actions:
Analyze Each Causal Identify (with green walls)
Root Cause Tree®
safeguards to incident that
were in place and worked
Analyze Each Root as intended
Adding Additional
Safeguards:
Safeguards Identify (with black or
SnapCharT® Software
blue) safeguards to add
Report & Implement
to prevent incident’s
recurrence
Use Safeguards Analysis
to Find Causal Factors
4/7/1996 8:30 AM 9:10 AM

cabinet information
Followed treatment Ointment container is left at patient's
prescribed by contains ten one treatment Ointment is applied twice
per container bedside
primary physician treatments daily to chest by nursing staff
Nurse was at the end

Locked Cabinet Used as a second check
of the shift vs. the patient chart Hospital policy states that all
medications should be in the
Has been working
double shifts for
previous four weeks
9:20 AM 10:15 AM
Patient
headache
No check of patient's
room for medications Spouse believes the
or hazards (required ointment is denture cream Patient requires close
by policy)
monitoring due to

Use Safeguards Analysis
to Find Causal Factors
4/7/1996 8:30 AM 9:10 AM

cabinet information
Followed treatment Ointment container
one treatment is left at patient's
prescribed by contains ten Ointment is applied twice
per container bedside
primary physician treatments daily to chest by nursing staff
Nurse was at the end Used as a second check

of the shift Locked Cabinet
vs. the patient chart Hospital policy states that all
medications should be in the
Has been working
double shifts for
previous four weeks
9:20 AM 10:15 AM
Patient
headache
No check of patient's
room for medications Spouse believes the
or hazards (required ointment is denture cream Patient requires close
by policy)
monitoring due to

Step 7: Report & Implement
Corrective Actions
SnapCharT®
1 Get Started
Root Cause Tree®
Determine
SnapCharT®
Define
Analyze Each Causal

Root Cause Tree®
Analyze Each Root


Safeguards

Presenting Your Findings
When Presenting to Management
Provide Information Needed for Their Decisions
Address:
• Interests of Your Audience
• Issues That Relate To Their “Hot Buttons”
• Return On Investment For Corrective Actions

Presenting Your
Investigation Results
State Incident
and its Results (in one sentence)
Present in 5 – 10 minutes:
• SnapCharT®
• Visual Aid
• Corrective Actions Report

Visual Aids
for Presentations
Use Only What Your Audience

Needs to Aid Their Understanding
• Drawings / Sketches
• Photographs
• Video of scene or simulated walk-through
• Piping & Instrumentation Diagrams
• Schematics
• Failed equipment parts and components
• Logs
• Test results
Winter SnapCharT®
Presenting to Management

SnapCharT®


cause analysis)

Sample Presentation
Investigation Findings
Deice Incident
Sample Presentation
10/30/2006
30 Min prior to
Agent #1 chooses to Agent #2 tells flight Aircraft
QX New Deice Truck departure. Captain Agent #1 completes
spray the aircraft with crew aircraft sprayed Takesoff with
Frozen over from low tells Agent #1 he spraying Aircraft with
Type I fluid using with Type I and Type only Type I
overnight temps wants Type I & IV Type I fluid
Skywest truck IV fluid sprayed
sprayed.
Sample Presentation
10/30/2006
30 Min prior to
Agent #1 chooses to Agent #2 tells flight Aircraft
QX New Deice Truck departure. Captain Agent #1 completes
spray the aircraft with crew aircraft sprayed Takesoff with
Frozen over from low tells Agent #1 he spraying Aircraft with
Type I fluid using with Type I and Type only Type I
overnight temps wants Type I & IV Type I fluid
Skywest truck IV fluid sprayed
sprayed.
Agent #1 does not Agent #2 does not

Water not drained tell Agent #2 that notice that only
from hoses after test he is now the DC Type I fluid sprayed
Load Coordinators Type I and IV

QX Type I truck normally act as Agent #2 was unfamiliar
fluid is
OOS that morning Deice Coordinators with Skywest's equipment
distinguishable to
and type I limitation
a trained deicer
Water sprayed thru No load coordinators

hoses to test available that Type I fluid is Skywest trucks look
morning pink in color similar to QX Type I
& IV trucks
Hoses froze that

Type IV fluid is
morning Agent #1 thought
green in color Verbiage Card not
could deice aircraft
and has a thick used
faster than Agent #2
New QX truck consistency
designated to spray
Type I & IV Agent #2 assumes Verbiage Card not
the role as deice available for use
coordinator
Trained deice agents This was Agent #2's his

can act as either sprayer first deice event under
or coordinator actual conditions
Sample Presentation
Sample Presentation
Sample Presentation
Deice Incident
Causal Factor:
Water not drained from hoses after test
Root Cause Corrective Action

No Policy or Add SOP requiring drainage of water from hoses of
Procedure deice truck after testing or addition of glycol to hoses
after testing.
Sample Presentation
Deice Incident
Causal Factor:
Agent #1 does not tell Agent #2 that he is the deice coordinator

Crew Teamwork Train the person-in-charge to examine a scenario as
Needs a whole instead of focusing on just what he or she
Improvement can accomplish/contribute.
Develop supervisory displays that highlight overall

mission requirements and help the supervisor/team
leader maintain the "big picture" view of the system
during emergencies or unusual conditions.
Sample Presentation
Deice Incident
Causal Factor:
Agent #2 does not notice that only Type I fluid sprayed

Practice / Agent needs more opportunity to act as a deice
Repetition Needs coordinator in order to become more proficient.
Improvement Consider shadowing an experienced agent when
manpower is available.
Sample Presentation
Deice Incident
Causal Factor:
Agent #2 does not notice that only Type I fluid sprayed

Not qualified Implement an OJT certification process for deice
coordinators.

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Analyze Each Causal

Corrective Action Helper®

What key pieces of Who needs to be interviewed?

Lights Out Reported 4

Start by defining the INCIDENT

It may be the worst thing that happened.

(Dashed box or oval = assumption … not yet proven fact)

Events are actions – use active verbs

Only one action per box

Sequence in chronological order (real time)

Use job titles/functions instead of names to reduce a blame focus

What Who Did What

More Info Lights Out Lights Out Lights Out

Use passive verbs Clarifying facts/data –

Use job titles/functions instead of names

- Precise & Quantified - Dashed Oval

Summer Complete sequence and ALL conditions

Prune unnecessary information. Reorganize. Define

Cut to only what’s needed to understand causal

Look at nurse’s work

Spouse picks up and Nurse enters

Obtain copy of hospital policies &

Has been working

No check of patient's room Spouse believes the

The tube containing ointment

1. Read the preliminary report.

(Who Did What? Or What Did What?)

Spring Get Started: What do I know? What information

Summer Complete sequence and ALL conditions

Prune unnecessary information. Reorganize. Define

Cut to only what’s needed to understand causal

Report & Implement SnapCharT® Software

A Quick Way to Find Causal Factors

Something that allowed the incident to occur or made it worse.

mechanics did not

What equipment failed or did not work as intended?

mechanics do not position

Who did what

So what resulted because mechanics mechanics do not position

Causal Factor: mechanics did not

Who did what

wrong? mechanics have

So what resulted because mechanics

Worker starts Worker leans to Worker falls

Worker thinks this What problems do you see?

Work plan calls What’s the Causal Factor?

Worker starts Worker leans to Worker falls

Worker does not

Work plan calls

Try to identify only 1 Causal Factor per

Worker thinks this Fall protection

What are the Appears to shut

Stop button failures Procedure requires

Appears to shut So what Operator in a hurry

Employee A Employee Employee B notifies

no funds for pothole problem Security reported

no request for work order Step 1:

Employee A Employee Employee B notifies

no funds for pothole problem Security reported

no request for work order

A More Detailed Approach to Find Causal Factors

pothole problem Security reported

work order conditions if