Azuca, Peru – 5.

400 m

Introducción al Tap Root

Noviembre 2012
¿Qué es Tap Root?

TapRooT®
Cambiando la forma en que el Mundo
Soluciona los Problemas

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 ¿ Qué es Tap Root?

Tap Root es un proceso sistemático desarrollado para solucionar

problemas encontrando su causa raíz.

Causa Raíz: es la causa (o causas) básicas que pueden ser

identificadas de manera razonable en las que la gerencia tiene el control
para solucionar y que cuando se solucionan, van a prevenir (o reducir
significativamente la probabilidad de ocurrencia) la recurrencia del
problema.

O también visto desde otro punto de vista….

Un causa raíz es la ausencia de una buena práctica o la falla en poder

aplicar el conocimiento que hubiera evitado un problema.

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 Hacer las preguntas correctas

No buscar culpables

1. Qué Pasó?
2. Cuáles son los Problemas?
3. Qué Originó esos Problemas?
4. Cómo Solucionar los Problemas y Evitar
que se repitan?

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Proceso de Investigación
TapRooT® 7-Pasos
Pasos Técnicas
1 Planificar Investigación SnapCharT® Primavera
Comenzar! Arbol de Causas Raíz®

Qué? 2 Determinar
Secuencia de Eventos SnapCharT® Verano

Definir
3 Factores Causales SnapCharT® Otoño

Analizar la Causa Raiz

Por Qué? 4 De cada Factor Causal
Arbol de Causas Raiz®

Analizar la Causa Generica Arbol de Causa Raiz®

5 De Cada Causa Raiz

Desarrollar y Evaluar
6
Solucionar Acciones Correctivas

Presentar / Reportar SnapCharT® Invierno

7 e Implementar
Acciones Correctivas Software TapRooT®

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Cambiar el Foco a “Que Ocurrió”

Eventos Incidente Eventos

Amplian la informacion sobre

un Evento - Qué? y Como?

Condiciones

Hechos comprobados y
preguntas, NO SON
Opiniones, juicios de valor, 6etc.
SnapCharT® - y su Simbología

Acción – “Quien hizo Qué y Cuando?”, o “Qué hizo que y

Cuando?”
EVENTO Una Acción por Recuadro
Sin nombres de personas – Solo Posiciones de Trabajo
Factual y sin Juicios de Valor

Información – Información de soporte relacionada al

CONDICION evento o acciones
Factual y sin juicios de valor
Cuantificarlo de ser posible
Acción u Ocurrencia que esta siendo investigada
INCIDENTE generalmente lo peor que pasó

Conector de Página – Muestra conexiones de página a

través de múltiples páginas

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Ejemplo de SnapCharT® - Vuelco
Camioneta

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Ejemplo de SnapCharT® - Vuelco
Camioneta

FACTORES
CF CAUSALES
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 Definición de Factores Causales

Factores Causales: Errores o fallas que si hubieran sido corregidas podrían haber
prevenido que ocurriera el accidente o hubieran mitigado significativamente las
consecuencias del mismo. NO BUSCA CULPABLES

Si el Jefe de Faena hubieran bajado de inmediato al trabajador a la

ciudad a buscar su bolso en el mismo bus en que subió; no hubiera sido
necesario enviarlo manejando una camioneta….y tal vez no hubiera
ocurrido el accidente.

Si el Jefe de Faena hubieran enviado a un chofer de servicio

conduciendo el vehículo y no a un ayudante con poca experiencia….tal
vez no hubiera ocurrido el accidente.

Si el trabajador no hubiera conducido a velocidad excesiva ….tal vez no

hubiera ocurrido el accidente.

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Árbol de Causas Raíz TapRoot ®

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Análisis de Causa Raíz de Cada Factor
Causal – 15 Preguntas

Colocar Nombre de Factor Causal Aquí

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 Análisis de Causa Raíz de Cada Factor
Causal – Hacer 15 Preguntas
Todas las
respuestas
Cruz con círculos
Roja verdes nos
“NO” llevan a
analizar la
Círculo parte de
Verde atrás de la
“SI” hoja en el
“Categorías
de Causas
Básicas”

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 7 Categorías de Causas Básicas

PROCEDIMIENTOS (Checklists)

CAPACITACIÓN CONTROL DE
CALIDAD

COMUNICACIONES

SISTEMA DE ADMINISTRACIÓN

INGENIERÍA HUMANA

DIRECCIÓN DEL TRABAJO

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Análisis de Causa Raíz de Cada Factor
Causal

Encontramos una Causa Raíz en una Categoría,

ahora hay que buscar otras Causas Raíz en
otras categorías 15
 Análisis de Causa Raíz de Cada Factor
Causal
Causal Factor/Issue:

This is where the causal factor is written

START HERE with each causal factor/issue and select or eliminate each category to find root causes.

HUMAN NATURAL
EQUIPMENT OTHER
PERFORMANCE Pages 5-21 DISASTER /
DIFFICULTY * (SPECIFY)
DIFFICULTY SABOTAGE
*Note: Consider
Equifactor™ Analysis

DESIGN EQUIPMENT / PREVENTIVE / RE PEAT

TOLERABLE
PARTS PREDICTIVE FAILURE
FAILURE
DEFECTIVE MA INTENANCE

DE SIGN REVIEW PROCUREMENT MANAGEMENT SYSTEM

DE SIGN SPECS
PM NI
MANUFACTURING Co rre ctive
Specs Design Not Problem Not Independent Action
NI To Specs Anticipated Review NI HA NDLING No PM PM for
Equip NI corre ctive action NI
for Equip
equipment management of STORAGE corre ctive action
environment change (moc) NI not yet implemented
not considered hazard analysis NI QUALITY CONTROL tre nding NI

Human Performance NI = NEEDS IMPROVEMENT

May also substitute LTA (L ess Th an Adequate)
Troubleshooting Individual
Basic Cause Categories or PIO (Potential Improvement Opportunity)
(on back) to investigate
Guide Performance
(15 Questions) Pages 22-31 Team Basic Cause Categories
Directions: Performance (on back) to investigate
Answer all questions Was a person exces-
Yes HUMAN E NGINEERING Pages 31-33
and then refer to the siv ely fatigued, impaired,
indicated Basic Cause upset, bored, distracted Did verbal communications
WORK DIRECTION Yes
Ca tegories on the back or overwhelmed?
or shift change play a role CO MMUNICATIONS
of this sheet to inves- in this problem?
tigate the causes of WORK DIRECTION
the problem. Should the person have Yes Yes
had and used a written PROCEDURES Did failure to agree about TRAINING
Causal Factor/Issue:
procedure but did not?
This is where the causal factor is written
the who/what/when/where
HUMAN E NGINEERING of performing the job play CO MMUNICATIONS
a role in this problem?
STAR T HERE with each causal factor/issue and select or eliminate each category to find ro ot causes. WORK DIRECTION
Yes
Was a mistake made
PROCEDURES
while using a procedure? Was communication
needed across organiza- Yes
HU MAN NATURAL
EQU IPM ENT OTHER tional boundaries or with CO MMUNICATIONS
PERFORMAN CE Pages 5-21 DISASTER /
DIFFICULTY * (SPECIF Y) other facilities?
DIFFICULTY SABOTAGE
Were alarms or displays to Yes
*Note: Consider
Equifactor™ Analysis recognize or to respond to HUMAN E NGINEERING
a condition unavailable or
DE SIGN EQU IPMENT / PREVENTIVE / RE PEAT misunderstood?
TOLERABLE
PARTS PREDICTIVE FAI LURE Basic Cause Categories
FAILURE Ma nagement
DE FECTIVE MA INTENANC E Yes
TRAINING System (on back) to investigate
DE SIGN REVIEW PR OCUREMENT MA NAGEM ENT SYSTEM Were displays, alarms, controls,
DE SIGN SPEC S Pages 33-35
PM NI tools, or equipment identified or PROCEDURES
MA NUFACTUR IN G Co rre ctive operated improperly? Yes MANAGEMENT SYSTEM
Specs De sign Not Problem N ot Independent Action Was a task performed in a
HA NDLIN G No PM PM for HUMAN E NGINEERING
NI To Specs Anticipated Re view NI corre ctive act ion N I hurry or a shortcut used?
for Equip Equip NI WORK DIRECTION
equipm ent ma nagement of STORAGE corre ctive act ion Did the person need more skill/ Yes
not yet implem ented knowledge to perform the job or to TRAINING
environment change (moc) NI
not considered hazard analysis N I QU ALITY CONTROL tre nding N I respond to conditions or to under- Had management been Yes
WORK DIRECTION MANAGEMENT SYSTEM
stand system response? warned of this problem or
had it happened before?
Human Performance NI = NEEDS IMPROVEMENT
Ma y also substitute LTA (L ess Th an Adequate)
Troubleshooting Individua l
Basic Cause Categories or PIO (Potent ial Improvement Opportunity) Was work performed in an Yes
(on back) t o invest igate MANAGEMENT S YSTEM
Guide Perfor mance adverse environment (such as Yes Were policies, admin.
HUMAN E NGINEERING controls, or procedures
(15 Questions) Pages 22-31 Team Basic Cause Categories hot, humid, dark, cramped, or WORK DIRECTION
Performance (on back) t o investigate hazardous)? not used, missing, or in
Dire ct ions: need of improvement?
Answer all questions Was a person exces- PROCEDURES
Yes HUMAN E NGI NEERING Pages 31-33
and then refer to the sively fatigued, impaired,
indicated Basic Cause upset, bored, distracted Did verbal communications TRAINING
or overwhelmed?
WORK DIRECTION Yes Did work involve repetitive
Ca tegories on the back or shift change play a role Yes Should an independent Yes
of this sheet to inves- CO MMUNI CATIONS Revised 3/20/00 motion, uncomfortable
in this problem? positions, vibration, or HUMAN E NGINEERING quality control check QUALITY CONTROL
t igate the causes of Copyright © 2000 by
WORK DIRECTION heavy lifting? have caught the problem?
t he problem. Should the person have Yes Yes System Improvements, Inc.
WORK DIRECTION
had and used a written PROCEDURES Did failure to agree about TRAINING Knoxville, Tennessee, USA
procedure but did not? t he who/what/when/where All Rights Reserved
HUMAN E NGI NEERING of performing the job play CO MMUNI CATIONS Duplic ation P rohibited Co ntinue on back by analyzing the indicated Basic Cause Categories
a role in this problem?
Yes WORK DIRECTION
Was a mistake made
PROCEDURES
wh ile using a procedure? Was communication
needed across organiza- Yes
tional boundaries or with CO MMUNI CATIONS
other facilities?
Were alarms or displays to Yes
recognize or to respond to HUMAN E NGI NEERING
a condit ion unavailable or
misunderstood? BASIC CAUSE CATEGORIES
Ma nagement Basic Cause Categories

Were displays, alarms, controls,

Yes
TRAI NING System (on back) to investigate

TRAINING QUALITY CONTROL

BASIC CAUSE CATEGORIES
tools, or equipment identified or PROCEDURES
Pages 33-35 PROCEDURES
operated improperly? Yes MANAGEMENT SYSTEM
HUMAN E NGI NEERING Was a task performed in a
hurry or a shortcut used?
WORK DIRECTION PROCEDURES TRAINING QUALITY CONTROL
Did the person need more skill/ Yes
knowledge to perform the job or t o TRAI NING Not Used / Wrong Followed Incorrectly No Training Understanding No QC NI
respond t o conditions or to under- Had management been Yes Not Followed NI Inspection
WORK DIRECTION MANAGEMENT SYSTEM format confusing
stand system response? warned of this problem or inspection
typo task not learning
had it happened before?
no procedure > 1 action / step inspection Not Used / Followed Incorrectly No Training Understanding No
analyzed objective instructions Wrong QC NI
sequence wrong excess references not Inspection
Yes procedure NI NI Not Followed NI
Was work performed in an
MANAGEMENT S YSTEM facts wrong mult unit references required format confusing
adverse environm ent (such as Yes Were policies, admin. not available or decided lesson inspection typo task not learning inspection
HUMAN E NGI NEERING controls, or procedures limits NI no hold no procedure > 1 action / step inspection
hot, humid, dark, cramped, or WORK DIRECTION inconvenient situation not not to plan NI techniques analyzed objective instructions
hazardous)? not used, missing, or in
point sequence wrong excess references not
need of improvement? for use covered details NI train NI procedure NI NI
PROCEDURES instruction facts wrong mult unit references required
procedure wrong revision data/computations no learning hold not available or decided lesson inspection
NI foreign limits NI no hold
Did work involve repet itive TRAINING difficult to use used wrong or incomplete objective point inconvenient situation not not to plan NI techniques
practice/ material
Re vised 3/20/00 mo tion, uncomfortable Yes Should an independent Yes
procedure use graphics NI not for use covered details NI train point NI
HUMAN E NGI NEERING quality control check QUALITY CONTROL second checker repetition exclusion
Co pyright © 2000 by positions, vibration, or
not required performed instruction
heavy lifting? have caught the problem? needed no checkoff NI during procedure wrong revision data/computations no learning hold
System Improvements, Inc.
WORK DIRECTION but should be NI foreign
Knoxville, Tennessee, USA checkoff misused work NI difficult to use used wrong or incomplete objective point
testing NI practice/ material
All Rights Reserved
Co ntinue on back by analyzing the indicated Basic Cause Cat egories misused second check continuing procedure use second checker graphics NI not exclusion
Dupl ic ation P rohibite d repetition
ambiguous instructions training NI not required needed no checkoff performed during
NI
equip identification NI but should be work NI
checkoff misused testing NI
misused second check continuing
COMMUNICATIONS MANAGEMENT SYSTEM
ambiguous instructions training NI
equip identification NI
Standards, SPAC Oversight / Corrective
No Comm. or Turnover Misunderstood MANAGEMENT SYSTEM
Policies, or Not Used Employee Action COMMUNICATIONS
Not Timely NI Verbal Comm.
Admin Controls Relations
(SPAC) NI comm. of infrequent corrective
no method no standard standard
terminology SPAC NI audits & action Standards, SPAC Oversight / Corrective
available turnover No Comm. or Turnover Misunderstood
process not used no SPAC evaluations NI Policies, or Not Used Employee Action
recently Not Timely NI Verbal Comm.
late (a & e) Admin Controls Relations
not strict changed corrective
communi- turnover repeat back a & e lack (SPAC) NI comm. of
enough action no method no standard standard infrequent corrective
cation process not used enforcement depth not yet terminology SPAC NI audits & action
not used confusing NI available turnover
long message a & e not implemented not used no SPAC evaluations NI
or incomplete process recently
turnover noisy no way to independent late (a & e)
technical not strict changed corrective
process environment implement employee communi- turnover repeat back a & e lack
error enough action
NI accountability communications NI cation process not used enforcement depth not yet
drawings/ NI no employee feedback not used long message confusing NI a & e not implemented
prints NI or incomplete independent
turnover noisy no way to
process environment technical implement employee
HUMAN ENGINEERING IMMEDIATE SUPERVISION
NI error communications NI
accountability
drawings/ NI no employee feedback
Human - Machine Work Non-Fault prints NI
Complex Preparation Selection Supervision
Interface Environment System Tolerant System of Worker During Work
HUMAN ENGINEERING IMMEDIATE SUPERVISION
labels NI housekeeping knowledge- errors not no preparation no
not
arrangement/ NI based decision detectable work package qualified supervision
placement hot/cold required NI Human - Machine Work Non-Fault
errors not fatigued Complex Preparation Selection Supervision
displays NI crew
rain/snow monitoring > 3 recoverable pre-job briefing upset Interface Environment System Tolerant System of Worker During Work
teamwork
controls NI items at once NI
lights NI substance NI labels NI
monitoring walk-thru NI housekeeping knowledge- errors not no preparation not no
alertness NI noisy abuse NI based decision detectable
lock out / arrangement/ work package qualified supervision
plant/unit high radiation/ team placement hot/cold required NI
tag out NI errors not fatigued
differences contamination selection crew
scheduling displays NI monitoring > 3 recoverable pre-job briefing
excessive cramped quarters NI rain/snow upset teamwork
NI controls NI items at once NI
lifting NI

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monitoring lights NI substance
tools/instruments NI walk-thru NI
Revised 2/27/96 alertness NI noisy abuse
NI = NEEDS IMPROVEMENT Copyright © 1996 by System Improvements, Inc. lock out /
plant/unit high radiation/ team
May also substitute LTA (Less Than Adequate) or PIO (Potential Improvement Opportunity) All Rights Reserved - Duplication Prohibited tag out NI
differences contamination selection
excessive scheduling NI
cramped quarters NI
lifting
tools/instruments NI
Revised 2/27/96
NI = NEEDS IMPROVEMENT Copyright © 1996 by System Improvements, Inc.
May also substitute LTA (Less Than Adequate) or PIO (Potential Improvement Opportunity) All Rights Reserved - Duplication Prohibited
 Desarrollo de Acciones Correctivas

Normalmente, las acciones correctivas se centran en las

siguientes 3:

 Disciplina
 Entrenamiento / Re-entrenamiento
 Mejora de Procedimientos

Debemos “pensar fuera de la caja” y mejorar el desarrollo

de acciones correctivas para evitar que lo problemas se
sigan repitiendo.

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 Desarrollo de Acciones Correctivas

DEBEN SER

Específicas
Detalladas. Describen las acciones correctivas necesarias para solucionar la causa raíz. Se
necesitan políticas/procedimientos/herramientas/EPP/Entrenamiento/etc. u otras condiciones
especiales necesarias para implementar la acción correctiva?

Medibles
Como vamos a verificar que la acción correctiva se cumplió tal como fue acordado?
(Verificación): ¿Quién va a hacerlo y con qué fecha limite?

Tener Responsables
Quien será responsable de implementar la solución y tienen ellos la autoridad y recursos
para hacerlo?

Razonables
Cual es el “caso de negocio” para esta mejora? Cual es el Retorno Sobre la Inversión (ROI) u
análisis Costo Beneficio en esta mejora? Cuales serían las consecuencias si la acción
correctiva no se implementa?
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 Desarrollo de Acciones Correctivas

DEBEN SER

En Tiempo
Cual es el tiempo razonable para implementar la acción correctiva? Se necesitan acciones
correctivas temporales antes de completar la solución definitiva para asegurar la seguridad,
calidad, producción o responsabilidad ambiental?

Efectivas
Como va a ayudar la acción correctiva a eliminar la causa raíz y prevenir que el factor
causal vuelva a ocurrir? Continuará siendo la acción correctiva efectiva en el futuro? Como
van a medir la efectividad luego de la implementación? (Validación)
Quien medirá la efectividad y con qué fecha limite?

Revisadas
Ha sido revisada la acción correctiva de manera independiente (por aquellas personas que
se verán afectadas – ingeniería – mantenimiento – EHS – supervisión – etc.) para prevenir
consecuencias no deseadas ? Genera esta acción correctiva algún otro tipo de riesgos que
deben ser revisados
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 Acciones correctivas a prueba de errores

Barreras de Seguridad Pasivas:

• Guardarail
• Airbag
• Fosa

Cual de éstos será una mejor

acción correctiva?
Barreras de Seguridad Activas (requieren la acción
humana):
• Señaleros / Guardias
• Carteles de Advertencia
• Cinturón de Seguridad
• Puente Levadizo

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 Desarrollo de Investigaciones de
Accidentes

• Todos los incidentes deben ser investigados (incluyendo los cuasi

accidentes)

• Todos los accidentes con tiempo perdido o accidentes de alto potencial

deben ser investigados bajo la metodología TAPROOT

• EL equipo de investigación debe ser designado y comenzar la investigación

dentro de las 24 horas de ocurrido el evento

• Todas las investigaciones de accidentes y análisis debe ser completado

dentro de los 7 días; salvo que por la complejidad del caso y circunstancias
se determine lo contrario

• Al finalizar la investigación y análisis las acciones correctivas deben ser

formalizadas e informadas en un plan escrito

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Desarrollo de Investigaciones de
Accidentes
PERSONAS INVOLUCRADAS EN LA INVESTIGACION Y ANALISIS DEL
Clasificación INCIDENTE BASADO EN LA CLASIFICACION DEL INCIDENTE
Severidad del del Incidente ZONE MANAGER/ PERSONAL DE
Incidente (riesgo GERENTE PERFORISTA/
GERENTE SUPERVISOR GERENTE LOGISTICA /
potencial) REGIONAL AYUDANTES/
EHS ZONA DE EHS OPERACIONES/ FLOTA /
EHS TESTIGOS
SUPERVISORES INGENIERIA
Bajo
Insignificante A RI R–A A ST
1-5
Moderado
Menor A RI R–A A ST
6-10
Moderado,
Tratamiento
Significativo
Medico con o sin A RI A R–A A ST
11-19
tarea/dias
restringidos
Catastrófico,
Extremo
Mayor, Lesión R RI A R–A A ST
20-25
con Días Perdidos

R = Responsable,
RI = Responsable de la Investigación y Análisis
A = Apoyo a la Investigación y recolección de datos
ST = Soporte Técnico / Expertos de ser requerido

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