Challenge
As the Supervisor of Health and Safety at Enmax Corporation (a municipal electric utility), I reviewed all incident reports. My observations were that quality of the reports varied greatly depending on the training, experience, and diligence of the investigator. There was little consistency in format and content from one report to the next. And the investigators tended to identify immediate causes (actions that went wrong) rather than root causes (the causes for the actions that went wrong).
Perhaps these problems were related to the investigation system we were using. It was time consuming and not very user friendly. And it didn’t provide us with a tool to clearly explain what happened and why it happened. Nor did it effectively track the status of corrective actions.
To me the challenge was obvious. If we wanted to learn more from the dear bought experience derived from accidents and incidents, then we needed to improve our investigation and root cause analysis.

Action
Fortunately, I had just been introduced to a system for incident investigation and root cause analysis called “TapRooT.” The action to take seemed clear. I needed to hold training for the people performing investigations so that they could use TapRooT to improve our investigation performance.

Result
The feedback from the participants in the training was that they left the course feeling confident that they had the skills they needed to use TapRooT to find the root causes of our incidents. They now had a new vocabulary of root cause analysis, a clear goal for their investigations, and the tools they needed to reach that goal.
However, the real test would be when they applied the techniques. What would I get? The answer was clear and obvious. I immediately noticed improvement in the quality and thoroughness of investigations and reports. This improvement and consistency meant that all the investigations were well above the minimum that I expected.
The software also helped improve the consistency of the reports and our analysis and the database helps us maintain our incident records. The Corrective Actions Reports are essential in completing the investigation loop by tracking the status of corrective actions and providing documentation that improvements have been implemented.
We are in the process of implementing the improved corrective actions that we are developing thanks to TapRooT. As time passes I’m sure that I will be sending you an additional success story with the statistical data that shows the impact of improved root cause analysis on our already good health and safety record.