TapRooT® System Minimized Blame and Repeat Occurrences
Moving away from blame-oriented methods to focusing on real root causes can be achieved. It takes dedication to changing culture, training, and commitment to improvement. Read how ComEd-Exelon approached this challenge and minimized blame and repeat occurrences.
Challenge
After attending the Global TapRooT® Summit, ComEd-Exelon wanted to implement the TapRooT® Root Cause Analysis System company-wide to ensure consistent and reliable investigation results. Identifying weaknesses in the work system would steer them away from ineffective blame-oriented methods to implementing solid fixes. They knew that to accomplish this, they would need to clear up misconceptions of those who were not familiar with the TapRooT® System through guidance and training. No small feat at a company with over 5,000 employees!
Action
The company first tackled changing employee perception of root cause analysis from “blame and shame” to “learn and mitigate.” The TapRooT® Software helped new users easily navigate the system. The company then implemented a better process for performing ACEs using essential TapRooT® Techniques to investigate low-to-medium risk incidents. They perform over 225 evaluations annually using a pool of over 150 TapRooT® trained evaluators. These types of evaluations are no longer a “best guess” because they have a solid process to find out what really happened to learn and make informed decisions about developing corrective actions.
Results
ComEd-Exelon successfully minimized blame culture by using TapRooT®’s systems approach to evaluating incidents. The robust framework helps them find root causes that will reduce the likelihood of experiencing the same problem, in the same way, again. They estimate they have reduced incidents at their company by over 50% using TapRooT® Root Cause Analysis and other proactive initiatives.
Submitted by: Vincent Vincek, Chair, North American Transmission Forum’s Human Performance Core Team
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