SAISAI’’ss BehaviorBehavior--based Root based Root Cause AnalysisCause Analysis

IEEE/HPRCT Conference, IEEE/HPRCT Conference, Monterey, CA Monterey, CA –– August 2007August 2007

Presented by: Dr. Tyrone TonkinsonPresented by: Dr. Tyrone TonkinsonPresident President -- Simple Approach, Inc.Simple Approach, Inc.

www.simpleapproachinc.comwww.simpleapproachinc.com

Presentation OverviewPresentation Overview

Worker Behavior and EventsWorker Behavior and Events–– Consequences shape behaviorConsequences shape behavior–– Basic learning loopBasic learning loopBehaviorBehavior--based Root Cause Analysisbased Root Cause Analysis–– Event timeEvent time--lineline–– Behavior screening questionsBehavior screening questions–– Recommended corrective actionsRecommended corrective actions

Consequences Shape BehaviorConsequences Shape Behavior

Aubrey DanielsAubrey Daniels’’ ABC AnalysisABC AnalysisAntecedent Antecedent -- Behavior Behavior -- ConsequencesConsequences

People have the capacity to learn.People have the capacity to learn.

People choose and adjust their behavior People choose and adjust their behavior based on their perception of likely based on their perception of likely consequences.consequences.

Perception of consequences comes from Perception of consequences comes from direct experiences and expectations direct experiences and expectations learned from others.learned from others.

ConsequencesConsequences

Consequences are Consequences are ““in the eyes of the in the eyes of the performerperformer”” -- his/her point of viewhis/her point of view–– Positive or NegativePositive or Negative

–– Immediate or FutureImmediate or Future

–– Certain or UncertainCertain or Uncertain

Consequences that are Immediate and Consequences that are Immediate and Certain have the greatest influence on the Certain have the greatest influence on the actions we choose (actions we choose (PICsPICs and and NICsNICs))

ABC Analysis ABC Analysis -- ExamplesExamples

Eating chocolateEating chocolate

SmokingSmoking

You are late for an important appointmentYou are late for an important appointment

Successful Task Execution Successful Task Execution --Basic Learning LoopBasic Learning Loop

Develop performance expectations that satisfy requirements

Document the performance expectations

Communicate to the worker and confirm understanding

Worker executes tasks in the work environment

Evaluation and feedback

Confirm applied knowledgeCoaching

Applying the Learning LoopApplying the Learning Loop

Are your supervisors monitoring and coaching Are your supervisors monitoring and coaching workers in the field?workers in the field?Are you using this information for continuous Are you using this information for continuous improvement?improvement?Sets up logical progression for behaviorSets up logical progression for behavior--related related eventsevents–– Are expectations defined?Are expectations defined?–– Have the expectations been clearly communicated and Have the expectations been clearly communicated and

understood by the worker?understood by the worker?–– Are the expectations being reinforced?Are the expectations being reinforced?–– Genuine knowledge and skill deficiency?Genuine knowledge and skill deficiency?

Case Study Case Study --Management Review MeetingsManagement Review Meetings

Corrective Action Review Board (CARB) Corrective Action Review Board (CARB) established to improve root cause qualityestablished to improve root cause qualityMember expectations to review and Member expectations to review and provide comments prior to meetingprovide comments prior to meetingFeedback from presenters that these Feedback from presenters that these actions were not occurringactions were not occurringApparent at meetings who was not Apparent at meetings who was not prepared prepared -- meeting effectiveness & report meeting effectiveness & report quality hamperedquality hampered

Actions and ResultsActions and Results

Developed a CARB presenter feedback formDeveloped a CARB presenter feedback form–– Standard questions about presenter knowledge Standard questions about presenter knowledge

and comfort with processand comfort with process–– List managers who provided feedback priorList managers who provided feedback prior

Used knowledge and comfort with process to Used knowledge and comfort with process to enhance presenter guidanceenhance presenter guidanceFeedback about manager involvement Feedback about manager involvement provided to senior managers provided to senior managers -- reinforced reinforced expectationsexpectations

If you want to change behaviors, you must change

the consequences.

BehaviorBehavior--Based InvestigationBased InvestigationTechnique uses knowledge of human Technique uses knowledge of human performance and behaviorperformance and behavior

Start with traditional timeStart with traditional time--line of events line of events (e.g., Event & Causal Factor charting)(e.g., Event & Causal Factor charting)

Use series of questions to evaluate human Use series of questions to evaluate human errors identified in timeerrors identified in time--lineline

Lends itself to a nice table in your reportLends itself to a nice table in your report

Evaluate recommended corrective actionsEvaluate recommended corrective actions

Event TimeEvent Time--LineLineUse facts to develop sequence of eventsUse facts to develop sequence of events

How should the task have been performed?How should the task have been performed?–– TrainingTraining

–– ProceduresProcedures

–– Talk with other experienced workersTalk with other experienced workers

Identify key actions or decision points Identify key actions or decision points where individuals deviated from where individuals deviated from requirements or expectationsrequirements or expectations

Behavior Screening QuestionsBehavior Screening Questions

The following slides walk us through the The following slides walk us through the table (see conference paper)table (see conference paper)

Go through all sections, because Go through all sections, because ……

There are always multiple reasons for There are always multiple reasons for eventsevents

Each section of the table includes Each section of the table includes suggested corrective actions suggested corrective actions –– consider consider them as you develop causesthem as you develop causes

Assignment of ResourcesAssignment of Resources

Is the worker qualified for task?Is the worker qualified for task?

Were there enough workers with the Were there enough workers with the correct qualifications?correct qualifications?

Are the tools and equipment adequate?Are the tools and equipment adequate?

PractitionerPractitioner’’s Examples Example

Attribute Findings Causes and/or Suggested Actions Assignment of Resources o Is the worker qualified for task? o Were there enough workers with

the correct qual’s? o Are the tools and equipment

adequate?

Reviewed the training and qualification records of all members of the crew. All personnel involved were qualified for the task. Interviewed the work crew supervisor to determine how he verifies qualifications prior to assigning work and confirmed an adequate process to do this. Crew member interviews indicate that sufficient number of people were on the job, with adequate tools and equipment.

No issues.

Clarity and Reinforcement of Clarity and Reinforcement of ExpectationsExpectations

Are the behavioral expectations clearly Are the behavioral expectations clearly defined?defined?

Have they been communicated and Have they been communicated and understood?understood?

Are they being reinforced in the work Are they being reinforced in the work environment?environment?

PractitionerPractitioner’’s Examples Example

Attribute Findings Causes and/or Suggested Actions Clarity and reinforcement of expectations o Are the behavioral expectations

clearly defined? o Have they been communicated and

understood? o Are they being reinforced in the

work environment?

Reviewed the following procedures: xxxx, yyyyy, and zzzz. Performance expectations for this task are clearly defined. Reviewed training records and found that all personnel on the crew completed course MA-123. Based on interview with the work crew, determined that they rarely see their supervisor in the field. Interview with crew supervisor revealed the same. Crew expectations are not being regularly reinforced in the field.

The crew supervisor cited numerous other work and administrative duties that are keeping him from spending more time in the field. Recommend: o A time-use study of the involved

supervisor’s activities. o Development of a field observation

schedule and reinforcement by the supervisor’s manager.

Quality of PerformanceQuality of Performance

Can desired performance be observed Can desired performance be observed and/or measured?and/or measured?

If so, is feedback provided?If so, is feedback provided?

Is Desired Performance Is Desired Performance Punishing?Punishing?

What are the consequences of doing the What are the consequences of doing the task as expected?task as expected?

Is it perceived as punishing?Is it perceived as punishing?

Is Undesired Performance Is Undesired Performance Rewarding?Rewarding?

What rewards, prestige, status, comfort, What rewards, prestige, status, comfort, or ease support the present undesired or ease support the present undesired way of doing the task (particularly when way of doing the task (particularly when shortcuts are taken)? shortcuts are taken)?

Are Consequences Used Are Consequences Used Effectively?Effectively?

What are the consequences for the What are the consequences for the worker of desired and undesired worker of desired and undesired performance?performance?

What are the consequences for the What are the consequences for the supervisor? Manager?supervisor? Manager?

Are there any consequences? Are there any consequences?

Genuine Knowledge or Skill Genuine Knowledge or Skill Deficiency?Deficiency?

Has the worker done this task in the past?Has the worker done this task in the past?

Have conditions changed since initial Have conditions changed since initial training / proficiency?training / proficiency?

Does the worker get sufficient practice to Does the worker get sufficient practice to retain skill? retain skill?

Are there Obstacles to Desired Are there Obstacles to Desired Performance?Performance?

Are there physical constraints to doing Are there physical constraints to doing the job correctly?the job correctly?

Were unexpected conditions a factor?Were unexpected conditions a factor?

Other Distractions?Other Distractions?

Were there any other physical or mental Were there any other physical or mental distractions? distractions?

Can the Person do the Job?Can the Person do the Job?

Does the person have the physical and Does the person have the physical and mental capacity to do this job?mental capacity to do this job?

Is the person overIs the person over--qualified?qualified?

Can the person change? Can the person change?

Successful Task Execution Successful Task Execution --Basic Learning LoopBasic Learning Loop

Develop performance expectations that satisfy requirements

Document the performance expectations

Communicate to the worker and confirm understanding

Worker executes tasks in the work environment

Evaluation and feedback

Confirm applied knowledgeCoaching

Questions / Comments?Questions / Comments?

About the Presenter: With over 23 years of experience in FortuneAbout the Presenter: With over 23 years of experience in Fortune 500 companies, 500 companies, TyTy has developed an exceptional reputation in the organizational dhas developed an exceptional reputation in the organizational development evelopment and problemand problem--solving business as a manager, evaluator, instructor, and consulsolving business as a manager, evaluator, instructor, and consultant. tant. He has a Ph.D. in Safety Engineering, Masters Degree in OrganizaHe has a Ph.D. in Safety Engineering, Masters Degree in Organizational tional Management, a Bachelor of Science Degree in Nuclear Engineering,Management, a Bachelor of Science Degree in Nuclear Engineering, and is a and is a licensed Professional Engineer. His management experiences inclulicensed Professional Engineer. His management experiences include de engineering, regulatory affairs, quality management, project manengineering, regulatory affairs, quality management, project management, and agement, and work coordination. work coordination. TyTy has provided consulting to utilities, machine shops, has provided consulting to utilities, machine shops, accounting offices, healthcare agencies, pharmaceutical manufactaccounting offices, healthcare agencies, pharmaceutical manufacturers, nonurers, non--profit profit agencies, and more. agencies, and more.

Contact Information:Contact Information:Tyrone S. Tonkinson, Ph.D., P.E.Tyrone S. Tonkinson, Ph.D., P.E.President, Simple Approach, Inc.President, Simple Approach, Inc.Phone: 570Phone: 570--407407--25532553Email: Email: ttonkinson@digitalttonkinson@digital--link.netlink.netwww.simpleapproachinc.comwww.simpleapproachinc.com