Challenge
We wanted to improve our incident investigations, root cause analysis, and corrective actions.

Action
In 2002, we decided that to reduce accidents, prevent injuries, and ultimately save money, we needed to do a better job investigating accidents. We investigated various improvement options and decided to try using the TapRooT System for investigation and root cause analysis.
Several of our staff attended System Improvements’ 5-day Advanced TapRooT Investigation Team Leader Training and received an individual user version of the TapRooT Software as part of the course. After the course we returned to apply the tools that we had learned to investigate bus and rail accidents, employee safety incidents, and safety issues.

Results
We immediately noticed improvements in our investigations.
The SnapCharT diagram drawn using the SnapCharT Software helped us understand the circumstances surrounding an incident.
The Root Cause Tree part of the TapRooT Software helped us analyze the root causes to a much greater level of detail. This better analysis and the Corrective Action Helper® Module of the Software helped us develop more effective corrective actions.
An unexpected but very valuable side benefit of our efforts has been the effect the TapRooT System has had on the interest of management in our investigations and their acceptance and support of the investigations and corrective actions.
Management has a much better understanding of what happened when we use the SnapCharT technique to present the incident to them. The presentation of the Safeguards (found using Safeguards Analysis) helps them understand how many or how few things had to fail to cause the incident. And management has commented that they now see corrective actions that they believe will be much more effective than before we started using TapRooT.
Because management support to pay for and assign resources to implement corrective actions is so important (because without implementation of corrective actions, your analysis effort is wasted) the new enhanced support by management may be the most important benefit that we have seen.
In summary, by using TapRooT we have achieved our goal of improved investigations, root cause analysis, and corrective actions. We also achieved a perhaps even more important benefit of enhanced management interest and acceptance of investigations and greater support for implementation of our corrective actions. This is helping us improve transit safety and operations and will eventually lead to cost savings.