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Triple Path Analysis

Triple Path Analysis. Getting to the Root of a Problem. Elements of the workplace. A Workplace consists of three basic elements:. People. Machines. Environment. Roots have several paths. When an incident occurs and/or a problem arises, where should we look for the “root cause”?

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Triple Path Analysis

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  1. Triple Path Analysis Getting to the Root of a Problem

  2. Elements of the workplace A Workplace consists of three basic elements: People Machines Environment

  3. Roots have several paths • When an incident occurs and/or a problem arises, where should we look for the “root cause”? • Logic tells us that we have to explore all of the potential paths to get to the solution, or in this case, the cause.

  4. Tunnel Vision • We can exhaust resources (time and money) chasing a path, only to find that it is a dead end. People -Training People have the knowledge

  5. Back to Basics • What happened? • Who was involved? • When did it happen? • Then start asking WHY? For each of the three workplace elements: What? Who? When? WHY?

  6. Mapping the Paths Factor 1 People Factor 2 Factor 3 Machines/Equipment Materials Cause Environment Culture

  7. People Training Aptitude Skill Experience Machines/Equipment Maintenance Age Internal modification Design vs. current use Materials handled and methods Environment Culture Physical environment Lighting Housekeeping Factors

  8. Discoveries • When you find a potential cause on any path, explore the cause using the 5 why’s. • Don’t stop the search with a discovery… explore each path until you have exhausted the search.

  9. Dead Ends • When you hit a dead end, don’t try to make the theory work! Move on. • If a path leads to a dead end… move to the next path.

  10. Loops • It is possible to have factors that continually lead back to the same factor. • What do you suppose this indicates?

  11. Switchbacks • Switchbacks occur when there is rapid change in direction. • Switchbacks indicate that your findings on one path have lead you directly to the other. Switchback

  12. Links • Links occur when potential causes are so closely related that they cannot be separated from each other. • For example: A potential cause could have both a people and environment component. Link

  13. Procedures • Do I need to draw all these diagrams? • How can I get all of this information? • Interview the reporting worker (near miss or incident) • Witness interviews • Loss runs (history) • Staff meetings • Team meetings or discussions

  14. Summary • To be a problem solver: • Explore the possibilities • Evaluate • Enhance • Educate • Enforce Incident Prevention Evaluate Enhance Educate Enforce

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