This presentation shows the possibilities of using Event Mapping in combination with Human Factor Analysis or Tripod Beta to solve problems related to human factors.

1. Copyright © 2015 CoThink Holding
Tripod Beta
and
CoThink RATIO
approach

2. 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

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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

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What is the RATIO Approach (2)?
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

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What is the RATIO Approach (3)?
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.

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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

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How to use RATIO (2)?
 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

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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
How to use RATIO (3)?

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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
How to use RATIO (4)?

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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

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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

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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

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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

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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

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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

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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: bart.smit@cothink.nl / +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