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We occasionally receive questions to clarify the difference between our Incident Investigation training course and our RCA Facilitator course so we thought we would address some of the most commonly asked questions in this Q&A-style article. We hope you find it helpful. And if you have any questions, as always, please don’t hesitate to contact us.

How is the “Incident Investigation” course different from the “RCA Facilitator” course?

The Incident Investigation course covers the process of identifying, obtaining, documenting, and preserving the raw data related to an incident, then constructing a general timeline of the incident. 

The RCA Facilitator course then trains our students on how to sort through this data using cause and effect principles to identify causes that are relevant and formulate workable solutions, or preventative measures, to prevent recurrence. There is also emphasis in the RCA Facilitator course on facilitation skills necessary to conduct the Apollo Root Cause Analysis methodology process.

What are the benefits of the Incident Investigation course? 

Without truly understanding the key elements and possessing the necessary skills to conduct a thorough, effective investigation, people run the risk of missing key causal factors of an incident while conducting the actual analysis. This could potentially result in not identifying all possible solutions including those that may be more cost effective, easier to implement, or more effective at preventing recurrence. The Incident Investigation course equips students with the knowledge and skills to conduct a proper investigation to prevent this from happening.

Why it is important for people to attend the Incident Investigation course?

Students will learn the key elements and develop the skills necessary to conduct and document a thorough, effective investigation ensuring all the pertinent information is available for the actual root cause analysis process. 

Students will learn:

• The nature of undesirable incidents and why they often repeat
• The value of a thorough, effective investigation – Why spend the time?
• Investigation lead and team selection – Matching individual traits and skill sets to the needs of the investigation
• The roles, or functions that must be filled to ensure thoroughness and reliability of data
• Possible sources of incident information and how to optimize the value and reliability of incident facts and evidence
• Demonstrations of misconceptions about the reliability of evidence and how to avoid them
• Critical interviewing skills for discovering valuable incident information without inadvertently tainting the outcome
• Options to ensure timely incident response so that valuable evidence can be preserved and collected
• The value of developing and using standard templates for use throughout the investigation process
• How to create an incident timeline using multiple sources of information
• Importantly, scaling the investigation effort based on the significance of the incident to avoid wasting precious resources while ensuring investigation thoroughness
• Hands-on individual and group exercises for practicing the key elements of the knowledge and skills listed above

Are there any prerequisites for the Incident Investigation course?

No. Students can take the Incident Investigation course on its own, or combine it with the RCA Facilitator course if they wish to learn the ins-and-outs of the Apollo Root Cause Analysis methodology as well. The Incident Investigation course is designed to stand on its own and depending on a person’s role, they may only need to attend one or the other, or both.

Is there an option to train my team in Incident Investigation via a private, onsite course?

Yes. We can work with a team within a company and create a customized Incident Investigation training course that takes into account their specific processes, triggers, industry, regulations, goals, stats of their HSE incidents, and incident severity tiers, and develop a course to their definitions and templates that can then be used to train staff across the company.

For more information, please contact us.

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Author: Jack Jager

When it comes to problems with quality in your operation, there are the obvious red flags—unhappy clients, defective products, poor reputation, delays, and exorbitant costs, to name a few. But there are other more subtle signs that your quality control department has room for improvement.

Your QC Department Looks Like a Firehouse

Those of us who work in quality control can easily fall into the pattern of fire fighting—running from one issue to the next, solving each problem in the near-term as it crops up. This can work okay for a time, but it’s not a great long-term strategy. When you only focus on solutions and never get down to the root causes that are creating your issues, you will find that the same types of issues keep occurring. “An ounce of prevention is worth a pound of cure” should be the mantra of every QC department. It’s worth the extra time up front to get at the root causes of an issue.

Your Quality Folks Aren’t Talking Cents

The universal language of business is dollars and cents, so if your quality control department isn’t translating your issues into actual cost to the business, they might not be heard. For example, you might calculate the cost of the time it takes to close different types of exceptions and add that information to your efficiency evaluations.  

There Is a Veil Over the QC Department

Sometimes the quality department is treated differently than manufacturing, engineering, or facilities when it comes to accountability. But it’s very important that QC personnel and their equipment are held to certain standards, too. While QC is often responsible for finding solutions, they also need to be held responsible for their share of the causes—for instance, the impact to the supply chain if raw materials or final product testing is not completed effectively. If there has never been an evaluation of your QC department’s process, it’s definitely time to QC your QC.

Your QC Department Sits in an Ivory Tower

Quality folks can do a much better job if they receive training in other areas, including manufacturing, validation, and project management. When a quality person is too specialized, it can prevent them from seeing the whole picture and finding more comprehensive solutions. If your QC department tends to be resistant to change, that might be a sign that it’s time to expand their horizons with some additional training outside their primary field of expertise.

Anything Short of Total Failure Is Considered Success

Let’s say you work for a chemical plant that manufactures plastic bags. You make a polymer that requires water, but the water you’re using has a bad bacteria in it. There is a corporate requirement that the water be clean, so the bacteria is a problem. However, the finished material passes the test even though there was a deviation earlier in the manufacturing process. So is it really a problem after all? If your client sees a pattern of failure within your process, they will begin to believe that you aren’t truly concerned with quality, even if the final product technically meets the specifications. Make sure that you’re taking all issues seriously, even if they don’t seem to affect the final outcome at first glance.

If any of these scenarios sound familiar, download our eBook “11 Problems With Your RCA Process and How to Fix Them” in which we provide best practice advice on using Apollo Root Cause Analysis to help eliminate problems in your QC process and beyond.

Author: Kevin Stewart

I recently wrote an article about auditing root cause analysis (RCA) investigations, and it only seemed appropriate to follow up with advice on auditing your overall RCA program. Let’s go back to the dictionary definition of “audit” -- a methodical examination and review. In my mind this definition has two parts: 1) the methodical examination and 2) the review. 

It might help to compare this process to a medical examination. In that case, the doctor would examine the patient, trying to find anything he can, either good or bad. This would include blood work, reflex test, blood pressure, etc. After that examination he would then review his findings against some standard to help him determine if any action should be taken. Auditing an RCA program is no different; first we must examine it and find out as much as we can about it, then we will need to review it against some standard or measure.

In my other article I discussed at length the measures against which an RCA investigation could be judged. Those still apply, and one of the program audit items can and should be the quality of the RCA investigation.

Now we are faced with determining the characteristics of a good program. A list of characteristics is given below:

• Quality of RCA investigations
• Trigger Levels are set and adhered to 
• Triggers are reviewed on a regular basis and adjusted as required to drive improvement
• A program champion has been designated, trained and is functioning
• Upper management has been trained and provides invloved sponsorship of the program
• Middle management has been trained and provides involved sponsorship of the program
• The floor employees have been trained and are involved in the process
• The solutions are implemented and tracked for completion 
• The RCA effectiveness is tracked via looking for repeat incidents
• Dedicated investigators / facilitators are in place 
  • Investigators are qualified and certified on an ongoing basis
• All program characteristics are reviewed / defined / agreed to by management and include: An audit system is defined, funded, and adhered to
  • Resource requirements 
  • Triggers
  • Training requirements are in place and funded
  • Sponsorship statements and support
• The RCA program is incorporated into the onboarding and continuous review training for new and existing employees

The next step in developing an audit is to generate a set of items that your program will be gauged against. This list can come from the items above, your own list, or a combination of the two. Once you have a final list of items to audit against, you need to generate a ratings scale. This can be a pass/fail situation or a scale that gives a rating from 0 to 5 for each item. This can allow you to give partial credit for some items that may not quite meet the full standard. You can also provide a weighting scale if deemed appropriate. This would mean that some of the items in the list had more importance or weight in the scoring based on the local feelings or culture of your facility. This scale can be anything you wish, but be cautious about making the scale too large. Can you really tell the difference between a 7 or 8 in a 10-point scale? Perhaps a 1 – 4 scale would be better?

Next, develop a score sheet with each item listed and a place to put a score for each one. It’s handy to add some guidelines with each item to give the reviewer a gauge on how to score the item. A sample of such guidelines might look like:

0    Does not exist

1    Some are in place but not correct

2    Many are in place and some are correct

3    All are in place but only some are correct

4    All are in place and most are correct

5    All are in place and correct

Don’t forget to leave a space for notes from the reviewer to explain the reasons for partial credit. With this in place either next to each item or easily available as a reference, it helps ensure consistency in the scoring, especially if multiple people will be scoring your RCA program.

The goal for a standardized audit process would be that several different people could independently review and score a program and would come up with essentially the same score. This may seem like a simple thing, but it turns out to be the largest issue because everyone interprets the questions slightly differently. There are several things you can do to minimize discrepancies:

1. Provide the information above to help.
2. Require the auditors to be trained and certified by the same process / people and then have them provide a sample audit and check it against the standard. Review and adjust any discrepancies until you are sure they will apply the same thinking against the real audit.
3. Always ensure that if multiple auditors are used in a program review, at least one has significant experience to provide continuity. In other words, don’t allow an audit to be done with all first-time auditors.

With these measures in place, all you have to do is review the RCA program against your list, score it, and have some sort of minimum for passing. Likewise you’ll want to have some sort of findings report where the auditor can provide improvement opportunities against the individual items instead of simply saying: “did not pass.”

These measures will ensure that the program is gauged against a consistent standard and can be repeated by multiple auditors. There will always be differences if multiple people are auditing an RCA program, but by utilizing the steps above these differences can be minimized to provide the highest level of credibility for the audit.

According to a definition applicable to the insurance industry, an accident is an event which is not deliberately caused and which is not inevitable[1]. A typical insurance policy has a significant number of exclusions that are the “evitable” circumstances.

Logically, any situation which is reasonably evitable and which likely has harmful consequences ought to have been identified.

Those of us who are the safety leads at our organizations have a lot riding on our shoulders. That pressure gives us a constant incentive to improve, because we can never do our job too well. This post highlights some of the questions we ask ourselves that ultimately ladder up to the larger question, “How can we do better?” 

For example:

1. How many injuries have been recorded at your location(s) in the past year? 

The often cited adage “you can’t manage what you don’t measure” is pertinent here. 

Data is king; knowing how many injuries have been recorded at all locations for your enterprise will not only enable comparisons between sites and an analysis of the common and different causes, but also can be used to motivate greater improvements at the lesser site(s).

2. Does that number include the near misses? Or aren’t they reported? 

The expression “near miss” clearly indicates a close call, but all too frequently it occasions relief rather than analysis. This is because people look on the bright side and put the escape down to good luck. Overcoming this complacency is a challenge. The issue for the organization is that all too often these events are simply not reported, or reported too long after the event to enable an accurate re-construction of the event. This compromises the ability to derive any “lessons learned” that could generate appropriate improvements.

3. Would you know if the near misses hadn’t all been captured? 

The simple fact is that “you don’t know what you don’t know”; this situation calls for a process of acknowledgement, if not reward, so that the incident participants have no fear of punitive measures being applied when they report the circumstances of the near miss. This necessitates the clear communication of a “no blame” philosophy. If employees feel that they will suffer some negative consequence they will be loath to volunteer information about the near-miss incidents.    

 4. Is your record improving?

Unless the data is being promptly collected, accurately recorded, and analyzed, trending will not be possible and improvement not apparent. The objective is to have a demonstrable improvement evidenced by the statistical record. The accuracy of this data will depend not only on the creation of the “no blame” culture but also on the refinement of the methodology and tools employed in the investigation of incidents. 

5. Have you set targets for improvement? 

Establishing fresh targets and goals periodically is the only way to ensure the improvement is continuous. Even a site with an almost blemish-free record needs to be totally vigilant about the changes that are being undertaken there. Change is the only constant and, regretfully, is also an opportunity for hazards and harm to arise. The fresh targets ought to be reflected in the key performance indicators (KPIs) applicable to the respective safety roles for your enterprise.

6. Are there any unidentified hazards facing the personnel? 

Only systematic inspection and auditing processes will reveal previously unrecognized hazards. The certainty that you have minimized risks and hazards will grow proportionally as the employees who encounter the hazards demonstrate their ownership of the safety program. They have the ultimate control of the likely causes of their own potential harm. But whether the personnel have accepted ownership of the program or not, it is incumbent on the responsible officer to implement the specific hazard identification process. This will necessitate close engagement with the plant or equipment operators, technicians, or any person with an exposure to their work environment. Yes, that’s everybody.

There are also hazards of the interpersonal type that may never be apparent to the observer; bullying and stress are increasingly the causes of substantial claims for compensation and can only be detected by building a trusting relationship with the personnel and developing confidentiality protocols.

 7. How effectively are you learning the lessons from each “accident”? 

The parlance “lessons learned” is commonplace but not consistently applied. These are words that express an intention to make improvements in the organization but all too often focus on the actors in the event rather than the systems and processes that are central to the business.

“Human error” is the categorical expression most commonly heard when blame is being attached and represents a plethora of mistakes that humans make. Discovering that precise error in this unique event and the reason(s) for it can add value and lead to preventive measures being implemented -- but not in isolation, not as the so-called “root” cause.

Perfect knowledge, perfect understanding, and perfect operation by all humans in the enterprise are a fantasy. Humans are fallible and accidents will happen if the situation exists.

 

8. Which causes are “evitable”? 

The “evitable” causes are simply the known, designed, or planned components of the situation – the hardware, equipment, systems, and processes that are used in the production of the goods or service in question. These are all possible causes which, with a human interface, can create hazards with potential negative safety consequences. They are the opportunities for establishing controls or installing barriers that prevent harm.

The safety program needs to identify improvements to the systems or equipment, which would at least minimize the likelihood of a repeat occurrence given the fallibility of the human factor. What are the possible failure modes or the mis-operations that could occur?    

9. Can you demonstrate that you have thoroughly and methodically analyzed every event in order to prevent recurrence?

A thorough and methodical causal analysis is not possible without the creation of a cause map. This is best achieved through a mediated process involving the pertinent stakeholders and subject matter experts and identifying and arranging the proven causes in a logical manner. It needs to be both comprehensive and comprehensible to win the confidence of the decision makers who are looking for recommendations that will effectively modify, substitute, or eliminate the causes.

There are regulatory authorities that have expectations in this sphere and will want to see the assiduous application of a method that has proven to be effective regardless of the industry or problem-type.   

[1] http://www.businessdictionary.com/definition/accident.html#ixzz3QpGESuXU

 ARMS Reliability is here to help you answer these questions. Our free eBook "11 Problems With Your RCA Program And How To Fix Them" is a great first step to figuring out “How can we do better?” Download it here.

 

Click on the infographic for a PDF version.