cothink ratio approach and tripod beta

Copyright © 2015 CoThink Holding

Tripod Beta

and

CoThink RATIO

approach

Copyright © 2015 CoThink Holding 2

Why use RATIO or Tripod Beta?

Objectives RATIO

Objectives Tripod Beta

Why use RATIO or

Tripod?

What is RATIO?

How to use RATIO?

What is Tripod?

How to use Tripod?

Key factors

Differences &

Similarities

Conclusion

Continuously improve the performance of processes and equipment

Improve and sustain improvement in a disciplined and structured way

Avoid “jumping to conclusions”

Visualise the total situation and analyse

Solve problems effectively and efficiently

Avoid problems in the future.

Help accident investigators model incidents in a way that allows

them to understand the influencing environment and uncover the

route organisational deficiencies that allowed that incident to happen

Please note in this presentation we focus on Tripod Beta, further mentioned as Tripod


What is the RATIO Approach (1)?

Reflect on the problem

Event Mapping (EM)

Analyse the problem

ProblemAnalysis

Human Factor Analysis (HFA)

Target actions

Decision Analysis

Implement actions

Risk Analysis

Observe and evaluate result

The 5 different RATIO steps & methodologies

For this comparison to Tripod we will limit to Event Mapping and Human

Factor Analysis

Why use RATIO or

Tripod?

What is RATIO?

How to use RATIO?

What is Tripod?

How to use Tripod?

Key factors

Differences &

Similarities

Conclusion



Event Mapping

Organise logically all factual known effects and causes of the problem

Visualise the already known chain of cause and effect, including any

contributing circumstances and breached barriers

Based on 5 Why, Apollo, Barrier Analysis, Fault Tree Analysis (FTA)

and years of RCA facilitation in practice

Human Factor Analysis

Identify the causes of human or organisational failure

Avoid jumping to conclusion or blaming

Examine carefully and systematically possible causes for undesired

behavior

Based on the work of Reason, Rummler and Brache

Why use RATIO or

Tripod?

What is RATIO?

How to use RATIO?

What is Tripod?

How to use Tripod?

Key factors

Differences &

Similarities

Conclusion



Why use RATIO or

Tripod?

What is RATIO?

How to use RATIO?

What is Tripod?

How to use Tripod?

Key factors

Differences &

Similarities

Conclusion

The combination of these methods leads to a

comprehensive insight in direct and organizational

causes completed with contributing circumstances and

breached barriers

Very useful for safety incidents, procedural failures etc.


How to use RATIO (1)?

By building an Event Map guided by the process

questions

Together with experts and problem owners

Organise logically all factual known effects and causes

of the problem

Visualise the already known chain of cause and effect,

including any contributing

circumstances and

breached barriers

Why use RATIO or

Tripod?

What is RATIO?

How to use RATIO?

What is Tripod?

How to use Tripod?

Key factors

Differences &

Similarities

Conclusion

Applying Event Mapping



By determining the causes that led to

the unwanted behaviour guided by the

process questions with the help of the

HFA tool

Together with the persons involved

Visualise and organise the causes in

the Event Map

Categorise the causes as: direct

causes, contributing circumstances or

breached barriers

Why use RATIO or

Tripod?

What is RATIO?

How to use RATIO?

What is Tripod?

How to use Tripod?

Key factors

Differences &

Similarities

Conclusion

Applying Human Factor Analysis


MaxGrip

Specialists in solutions for Asset Performance Management

Developers and suppliers of Optimizer+ and strEAM+, an integral IT-

solution for Reliability & Maintenance Engineering

Optimizer+ RCA Module

Simple drag and drop functionality to create Event Map

Connecting with automatic alignment of icons or with free placement

Possibilities to add pictures and remarks

Print / email function

Export function as “vector based image” (which can be used in

PowerPoint, Word, Excel, etc.)

Toyota A3 Reporting

Why use RATIO or

Tripod?

What is RATIO?

How to use RATIO?

What is Tripod?

How to use Tripod?

Key factors

Differences &

Similarities

Conclusion

Tooling for RATIO Methods



Optimizer+ offers Event Mapping, Problem Analysis, Human

Factor Analysis, A3 reporting and action logging

Why use RATIO or

Tripod?

What is RATIO?

How to use RATIO?

What is Tripod?

How to use Tripod?

Key factors

Differences &

Similarities

Conclusion



What is Tripod?

Using Tripod, incident investigators model incidents in

terms of:

Objects (something acted upon, such as a flammable substance

or a piece of equipment),

Agents (something that acts upon objects, such as a person or a

fire) and

Events (the result of an agent

acting upon an object, such

as an explosion)

Why use RATIO or

Tripod?

What is RATIO?

How to use RATIO?

What is Tripod?

How to use Tripod?

Key factors

Differences &

Similarities

Conclusion


How to use Tripod?

Working back from the 'main event' (the incident), this

allows the investigator to understand fully what happened

and how an incident happened:

To determine what barriers where in place to prevent those objects

and agents acting in the way they did and why they failed

To look at the immediate causes of either the act that led to the

incident, the psychological precursors to that, and ultimately

underlying organisational deficiencies

Why use RATIO or

Tripod?

What is RATIO?

How to use RATIO?

What is Tripod?

How to use Tripod?

Key factors

Differences &

Similarities

Conclusion


Event Map…

…divides the problem in sub problems with corresponding research and offers a

complete overview

…drives the RCA and addresses unknown causes, actions and decisions

…in combination with HFA does not target human actions as causes but carefully

analyses the causal relations between actions, circumstances, environment, feedback

and consequences

…displays clearly all research, improvement-proposals and follow up actions and are

secured in follow up methods such as Decision Analysis, Risk Analysis and Planning

…focusses on the ability to factual, concrete and specific formulation of the problems in

a causal way and target specific actions

…connects in multifunctional teams the available knowledge and experience and brings

a common insight

…visualises the whole process and is the focus for all the applied methods (PA, HFA,

Decision Analysis, Risk Analysis and other methods). Additional a report can be made

…includes all aspects of all RCA methods (agents, preconditions, breached barriers,

human factors etc.)

…addresses and analyses all causes (when chosen to be)

The key factors of EM & HFA (1)

From our perspective…

Why use RATIO or

Tripod?

What is RATIO?

How to use RATIO?

What is Tripod?

How to use Tripod?

Key factors

Differences &

Similarities

Conclusion


Event Map…

…maps effects of the Event to the business goals

…consists of: an Event, effects, causes, breached barriers, contributing circumstances,

unknown causes and actions

…follows a precise convention for the content: subject and deviation, subject and

condition or person + unwanted behaviour

…does not include possible causes. Only facts and analysed causes. When chosen to,

an unknown cause can be analysed

…combines direct causes with contributing circumstances and broken barriers

…is in combination with HFA applicable for technical failures and human factors

…is supported by software tooling (Excel, MaxGrip Optimizer+)

…is experienced by users as a thorough and honest process in which the outcomes are

practical and easy to implement

…and HFA are part of a holistic view (RATIO approach)

The key factors of EM & HFA (2)

From our perspective…

Why use RATIO or

Tripod?

What is RATIO?

How to use RATIO?

What is Tripod?

How to use Tripod?

Key factors

Differences &

Similarities

Conclusion


Differences & similarities (1)

Using RATIO Methods or Tripod Beta?

From our point of view EM with HFA has following

similarities with Tripod:

Brings the knowledge and experience of a multifunctional team

together and gains insights in a visual model

Are a visual and intuitive method

But it has also differences, the most eye catching:

Event Mapping drives not only the investigation but also plans and

secures the actions to avoid reoccurrence

Why use RATIO or

Tripod?

What is RATIO?

How to use RATIO?

What is Tripod?

How to use Tripod?

Key factors

Differences &

Similarities

Conclusion


Differences & similarities (2)

Differences between both methods

Event Mapping is a very convergent process (and thus time efficient)

without neglecting the conditions and barriers

Event Map can be used as a visual and causal basis for several other

analyses/methods

Event Map doesn’t includes possible causes / conditions

Event Map connects the effects of the Event to the business goals

where Tripod works back from main event to the cause(s) without

mentioning the effects

The Tripod process aims to analyse extensively and thoroughly from

all perspectives and reports this to all the stakeholders. This

consumes a lot of time and the value of the report isn’t always valued

as it should be

Why use RATIO or

Tripod?

What is RATIO?

How to use RATIO?

What is Tripod?

How to use Tripod?

Key factors

Differences &

Similarities

Conclusion


Conclusion

What’s most fitting?

It’s not Tripod or RATIO with EM/HFA but use the method

that’s most fitting for the situation, for example:

Start every Incident or RCA with an Event Map to map the effects,

causes, breached barriers and conditions

Decide on a Human Factor Cause whether to use Tripod or HFA

Use Problem Analysis in addition to the Event Map when causes are

unknown

For more contact: [email protected] / +31(0)613137978

Why use RATIO or

Tripod?

What is RATIO?

How to use RATIO?

What is Tripod?

How to use Tripod?

Key factors

Differences &

Similarities

Conclusion

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cothink ratio approach and tripod beta

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