Sweating the Small Stuff: Why TapRooT® Is Upping Its Game to Precursors

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System Improvements Inc. is pleased to announce an update to its brand language, action, and service regarding investigative initiatives. TapRooT®'s precursor initiative calls for small investigations at the early recognition—if not the earliest—of a problem or failure, since most incidents have warning signs and events that predate the incident.

There hasn't been a major accident that didn't contain precursors in the mix. I've never talked to a senior manager that thought a major accident was acceptable.

System Improvements Inc. is pleased to announce an update to its brand language, action, and service regarding investigative initiatives. TapRooT®'s precursor initiative calls for small investigations at the early recognition—if not the earliest—of a problem or failure, since most incidents have warning signs and events that predate the incident. TapRooT®'s precursor language is defined as follows:

A process safety incident typically involves an unplanned human or mechanical failure in a workplace, often involving a fire, explosion, rupture, or hazardous chemical leak. Many process safety incidents have low actual consequences. The reason they need to be prevented is that they are precursors to major accident. If one or more additional Safeguards fail, they become a major accident. As a result, their potential consequences are high. A precursor incident is an incident that could have been worse. If another Safeguard fails, if the sequence is slightly different, or if your luck proves worse, the incident results in a major accident, a fatality, or a significant injury. These incidents are often called “HIPos” (High Potential Incidents) or “potential SIFs” (Significant Injury or Fatality).

TapRooT® Cofounder Mark Paradies observes, “There hasn't been a major accident that didn't contain precursors in the mix. I've never talked to a senior manager that thought a major accident was acceptable. Most claim they are doing everything possible to prevent them. However, many senior managers don’t require advanced root cause analysis for precursor incidents. Incidents that don't have major consequences get classified as a low consequence event. People ask 'Why did this happen?' multiple times then implement ineffective corrective actions. Sometimes these minor consequence (but high potential consequence) incidents aren't even reported. Management is letting precursor incidents continue to occur until a major accident happens. And, after a major incident, CEOs want their lives back, but it's too late. It happens all the time."

Small precursor investigations pay off for companies who learn to conduct them by engaging TapRooT®. A TapRooT® client, a coal mining company, was experiencing two to three fatalities a year. The company engaged TapRooT® and, for years, the reduction in fatalities was 100 percent. TapRooT® performs quality investigations of precursor incidents all the time, employing the book Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents, and by training companies in a 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course. The course includes the essential tools necessary to successfully complete an investigation with essential TapRooT® techniques, and how to check corrective action effectiveness using the SMARTER technique. Basic TapRooT® techniques include:

  • SnapCharT®: a simple, visual technique for collecting and organizing information quickly and efficiently.
  • Root Cause Tree®: an easy-to-use resource to determine root causes of problems.
  • Corrective Action Helper®: helps people develop corrective actions by seeing outside the box.

About System Improvements Inc. – TapRooT®

Founded in 1988, TapRooT® solves hurdles every investigator faces. TapRooT® root cause analysis takes an investigator beyond his or her knowledge to think outside the box. Backed with extensive research in human performance, incident investigation, and root cause analysis, TapRooT® is a global leader in improved investigation effectiveness and productivity, stopping finger pointing and blame, improving equipment reliability, and fixing operating problems.

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Anne Roberts
System Improvements Inc.
+1 8655392139 Ext: 3340
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