Author Archives: Ken Reed

Advanced TapRooT® Root Cause Analysis Course In Salt Lake City

Posted: September 14th, 2012 in Courses

Bob Koonce and I just finished teaching a great course in SLC.  Here are some pictures:

Bob, hard at work:
















2-Day TapRooT® Root Cause Analysis Course for San Antonio Internacional in Bogotá

Posted: September 5th, 2012 in Courses

We completed a course for one of our clients in Bogotá, Colombia last week.  Piedad Colmenares taught this Spanish course.  Another happy group!











3-Day TapRooT® / Equifactor® Equipment Troubleshooting and Root Cause Analysis Course in Bogotá

Posted: September 4th, 2012 in Courses

We’ve completed another great course in Bogotá this month.  Here are some pictures from the course:

3-Day TapRooT® / Equifactor® Incident Investigation Course in Bogotá, Colombia

Posted: August 15th, 2012 in Courses

We just completed another great course in Bogotá this week.  Sounds like they had an excellent class!

Thank you to Marco Flores and Piedad Colmenares (our terrific instructors), and Diana Munévar, who did an awesome job hosting the course for us.

Bird Strike on 737 Causes Equipment Damage and Emergency Landing

Posted: August 2nd, 2012 in Accidents, Current Events

A flight descending into Denver experienced a bird strike.  Some significant external damage, but apparently no breach of the pressure hull.  The pilots appear to have done a good job responding to the strike.

Some external sensors were also damaged, with backup systems kicking in.  Aircraft equipment design needs to be robust enough to handle failures.
Here’s a link to one article:

UPDATE: Fire On Submarine USS Miami was no accident

Posted: July 23rd, 2012 in Current Events, Investigations

Seems the fire that broke out on board USS MIAMI on May 23 was a deliberate act of arson.  One of the civilian workers was stressed, taking prescribed medications, and wanted to go home early.  He set fire to some rags on a bunk in one of the berthing areas.

A few weeks later, he apparently set a second fire in the same drydock outside the sub, but it was much less severe.

See previous blog article:

Latest news article here:

The fire caused over $400 million in damage.  The Navy is still deciding whether the ship is salvageable or not.  Luckily, no one was injured, although it took over 10 hours and dozens of firefighters working in near-zero visibility to control the blaze.

As an aside, the original “cause” of the blaze was thought to be a fire in a vacuum cleaner that ingested something hot.  A solid investigation, along with good evidence gathering, helped narrow down the real issue.  Of course, I’m not convinced they are still at the final cause, but at least it looks like they are making progress on the investigation.

5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course for Shaw Group

Posted: July 23rd, 2012 in Courses

We held a 5-Day TapRooT® root cause analysis class for Shaw Group in Jenkinsville, SC last week.  Good to see nuclear construction ramping up, and starting off on the right foot with corrective action development and implementation.  Way to go Shaw Group!!

Nice t-shirts, too!

TapRooT® / Equifactor® Root Cause Analysis and Equipment Troubleshooting Class in Bogotá

Posted: July 9th, 2012 in Courses

Here are some pictures from a recent 3-Day TapRooT® / Equifactor® class held in Colombia:

2-Day TapRooT® Root Cause Analysis Investigation Course in Stamford, CT

Posted: June 14th, 2012 in Courses

Mel Lager and I just finished a great course in Stamford.  We had students from a wide range of industries (pharmaceutical, oil drilling and pipeline, airline, aerospace, fossil and nuclear power generation, etc).  Great class!

Let us know if you are interested in attending either one of our public courses, or if you would rather have us come right to your facility to teach TapRooT® to your team!

How Long Does an Investigation Take? How About 14 Years!

Posted: June 6th, 2012 in Current Events, Investigations, TapRooT® Instructor

One of our UK TapRooT® instructors (Alan Smith) was the lead investigator looking into the murder of Arlene Fraser in Scotland in 1998.  Her husband has just been convicted a second time for her murder. 

In 1998, Arlene Fraser was attacked by her husband Mat.  He was out on bond, and 5 weeks later, Arlene disappeared.  He apparently paid someone to kill his wife.  He was convicted of that murder in 2003, but then a technicality caused the conviction to be set aside.  This new trial has now again found him to be guilty, and he is back in prison.

You can see the story at this link:  At the 5:20 mark, you can see Alan describe his thoughts on the case.

This is an example where tenacity and attention to detail can finally win a result. 

5-Day TapRooT® Advanced Root Cause Analysis Course in Bogotá Colombia

Posted: June 4th, 2012 in Courses

We finished another Spanish-language TapRooT® course in Central America last week.  Here are some pictures from that course:

Let us know if you would like to arrange for a Spanish-language TapRooT® Course!

How To Test the Accuracy of Your “Why” Root Cause Analysis

Posted: June 1st, 2012 in Human Performance, Performance Improvement, Root Cause Analysis Tips

I recently received an inquiry asking me, “What is the test to assure true root cause is found?  We use the “Why-Why” Analysis.”

    Using one of the “why” methods (“Why-Why”, 5-Why’s, etc) unfortunately leads many investigators to question their methodology.  That’s because, after using it once or twice, it becomes pretty obvious that these methods are 100% dependent on the experience and biases of the investigator.  If you’re a training person, amazingly enough, your “why” analysis leads you to training problems.  If you’re a quality person, you end up with quality-related issues.

    That’s because these methods do not give you any expert guidance to get beyond the investigator’s current level of knowledge.  For example, if you don’t know anything about “human engineering” (what color should an alarm light be? what shape valve hand wheel should be used?), you will never look for these problems.  You will only find problems you’re already familiar with, and therefore you will only put corrective actions in place that you have probably already tried in the past.

    The question posed is exactly the right question.  “How do I know I’ve found the real root cause?”  The bad news is that only a highly-trained human performance expert can answer that without some type of expert guidance.  The good news is, TapRooT® was designed to give you exactly that expert guidance.

    TapRooT® was designed by human performance experts to guide the normal investigator toward the true root causes that a highly-trained expert would find.  It does this by supplying a series of simple “yes/no” questions that you answer in the course of your investigation.  The answers to those question will quickly narrow you down to the true root causes of human performance or equipment failures that actually led to the accident.  Once you have these root causes, you can then apply effective corrective actions to eliminate them, preventing similar human performance mistakes in the future.

    Now, instead of ending up with corrective actions like, “Counseled the operator on the importance of opening the correct valve” (like he doesn’t already know that!), you can now find out why he opened the wrong valve.  You can be confident that the root causes you have found are real, proven root causes… the real reasons good people make mistakes.

     To directly answer the question, “why” methodologies will not consistently get you to true root causes.  There is no test built into those methods to verify root causes are found.  There’s no electronic “magic bullet” that can work around the weaknesses in those systems.  You’ll have to go outside those methodologies to get there.  Give TapRooT® a try!  We guarantee you’ll be satisfied with the results.

5-Day Advanced TapRooT® Root Cause Analysis Course in Bogotá, Colombia

Posted: June 1st, 2012 in Courses

Gran Tierra hosted a 5-Day TapRooT® class last week in Bogotá, Colombia.  Piedad Colmenares and Nelson Suarez taught the course.

Let us know if we can schedule a course for your company.  We can teach in either English or Spanish!

Fire Ravages Submarine: Accdent Investigation Underway on USS MIAMI

Posted: June 1st, 2012 in Accidents, Current Events

A fire broke out on board the fast attack submarine USS MIAMI (SSN 755) at the Portsmouth Naval Shipyard in Kittery, Maine last week.  The fire took over 10 hours to put out, requiring 75 waves of firefighters to enter the ship in 10-15 minute shifts.  The forward compartment of the ship, containing the control room, living quarters, torpedo room, and auxiliary machinery spaces, was severely damaged by both the fire and the nearly 3 million gallons of water that were used to fight the fire.  The cause of the fire is under investigation by 3 separate teams.

Here’s a link to one of the stories.

Although not assigned as a crewmember, I actually rode on board MIAMI  at one time.  I was also assigned to several 688-class submarines during my career.  I can just imagine what it must have been like to fight a major fire onboard the submarine.  Next to flooding, fire is the most serious casualty a submarine can suffer in peacetime.  The power goes out, it becomes pitch black, you’re in tight quarters wearing bulky firefighting and respiratory gear, with no way for the heat to escape.  It rapidly becomes an oven.

Luckily, the submarine was in port conducting an overhaul.  All weapons had been removed, and no crewmembers were actually living on board.  7 crewmembers and local firefighters suffered minor injuries fighting the blaze.

TapRooT® and Equifactor® Root Cause Analysis and Equipment Troubleshooting Course in Pittsburgh

Posted: May 16th, 2012 in Courses

Teaching a 3-Day public course in Pittsburgh this week with Ken Scott.  We had a great group for the first 2 days:

I’ll be starting off with Equifactor® equipment troubleshooting tomorrow.

3-Day TapRooT® / Equifactor® Root Cause Analysis and Equipment Troubleshooting Course in Cartagena, Colombia

Posted: May 8th, 2012 in Courses

Just to mix it up a little, we just completed an ENGLISH LANGUAGE TapRooT® course in Cartagena last week.  We had a great group.  Diana Munévar made all the course arrangements.  I taught the course. 
Here’s the class picture:

Let us know if you need a course in Central or South America, in Spanish, Portuguese, or English.

TapRooT® 2-Day Incident Investigator Root Cause Analysis Course in Papua New Guinea

Posted: May 1st, 2012 in Courses

Oil Search Limited hosted a series of 5-Day and 2-Day courses in PNG this month.  Here are a few pictures from one of the courses:

View photos from the 5-Day in Papua here.  This course was taught by Michael Podgorny from Practical Solutions Group, one of our providers in Australia.  He’s based out of Perth.
Congratulations to the new TapRooT® users!

TapRooT® 5-Day Advanced Root Cause Analysis Class in Lima Peru

Posted: May 1st, 2012 in Courses

We held a public TapRooT® course last week in Lima, Peru.  The course was planned by Diana Munévar of T&PS out of Bogotá, Colombia.  The instructors were Piedad Colmenares and Nelson Suarez.  Looks like they had a VERY successful class.  Congratulations to all the graduates!

TapRooT® / Equifactor® Root Cause Analysis and Equipment Troubleshooting Course in Bogotá, Colombia

Posted: April 24th, 2012 in Courses

We held another full TapRooT® course in Bogotá last week.  Colombia is certainly a popular place for improvement programs!

Thanks to Nelson Suarez and Marco Flores for teaching the course, and Diana Munévar for setting up the great venue!

Let us know if you are interested in attending or hosting a TapRooT® course in your area.

TapRooT® / Equifactor Root Cause Analysis and Equipment Troubleshooting Course in Bogotá, Colombia

Posted: February 17th, 2012 in Courses

We completed another successful course in Bogotá this week. Diana Munévar (far left) organized the course, with Marco Flores (next to Diana) and Piedad Colmenares (far right) providing excellent instruction.  Great Job!

TapRooT® Equifactor® Root Cause Analysis and Equipment Troubleshooting Course in Bogotá, Colombia

Posted: February 14th, 2012 in Courses

We are busy in Colombia!  We just completed 2 courses in the past 2 weeks in Bogotá.  Here are some pictures from one of the courses:

Great looking group of root cause analysis experts!

Russian Missile Submarine Accident More Serious Than Originally Reported

Posted: February 14th, 2012 in Accidents, Current Events

On December 29 of last year, the Russian Submarine Yekaterinburg suffered a fire while in drydock.  The fire sent flames 30 feet into the air and took many hours to extinguish.  This submarine is a Delta IV class ballistic missile submarine, with 2 nuclear reactors for propulsion and power.

Original reports said that the fire originated in wooden scaffolding around the outside of the ship, with the fire spreading to the rubber acoustic coating on the exterior of the hull.  Russian authorities said that all weapons had been removed, and the fire was limited to the exterior of the vessel.

However, recent reports indicate that the torpedoes and missiles were in fact on the ship.  The fire appears to have occurred in the free-flood area on the exterior of the torpedo room.  A large hull cut is visible.  It appears they needed external access to the torpedo tubes or sonar system, which are outside the main pressure hull, but inside the ballast tank / free-flood area.  The hull cut in the pictures looks quite extensive.

Sailors allegedly had to manually remove torpedoes from the tubes (hydraulics had been deactivated for the maintenance) to prevent explosions.  According to the reports, while the torpedoes and missiles are normally removed from the the ship prior to dry-docking, the military wanted to get the ship back to sea quickly, so they left the torpedoes and missiles on board.

This may be a great example of taking short-cuts to get the job done quickly.  The military had requirements to remove ordinance prior to dry-docking, but decided it would delay the schedule too much.  A minor fire in a wooden scaffolding ended up nearly destroying the submarine.

5-Day TapRooT® Advanced Team Leader Root Cause Analysis Course for T.D. Williamson in Tulsa, OK

Posted: February 13th, 2012 in Courses

Tommy Garnett (one of our outstanding TapRooT® instructors) just finished teaching a course for T.D. Williamson.  What a terrific group.  Thanks for your enthusiasm!

Rocket Barge Hits Bridge in Kentucky

Posted: January 27th, 2012 in Accidents, Current Events

The Delta Mariner struck the Eggner Ferry Bridge in southwest Kentucky, knocking down 2 spans of the bridge.  Motorists almost didn’t notice the missing spans as they came up to it in the dark.

The barge is designed to carry Delta 4 and Atlas V rocket stages from the assembly plant in Decatur, Alabama.  No word if there were any rocket components on board.

A later report indicates that the barge took the wrong channel.  It apparently attempted to use the recreational channel (for small private boats), instead of using the main navigational channel. 

On-Site TapRooT® / Equifactor® Root Cause Analysis Course in Bogotá, Colombia

Posted: January 20th, 2012 in Courses

ARP Colpatria hosted a 3-Day TapRooT® and Equifactor® Root Cause Analysis and Equipment Troubleshooting course this week.  They had a great class with lots of learning, with some fun thrown in for good measure.

Here’s some creative solutions during the Marble Drop game:

Looks like a full class!

Connect with Us

Filter News

Search News


Angie ComerAngie Comer


Anne RobertsAnne Roberts


Barb CarrBarb Carr

Editorial Director

Chris ValleeChris Vallee

Human Factors

Dan VerlindeDan Verlinde

VP, Software

Dave JanneyDave Janney

Safety & Quality

Garrett BoydGarrett Boyd

Technical Support

Ken ReedKen Reed

VP, Equifactor®

Linda UngerLinda Unger


Mark ParadiesMark Paradies

Creator of TapRooT®

Per OhstromPer Ohstrom

VP, Sales

Shaun BakerShaun Baker

Technical Support

Steve RaycraftSteve Raycraft

Technical Support

Wayne BrownWayne Brown

Technical Support

Success Stories

Alaska Airlines adopted System Safety and incorporated TapRooT® into the process to find the root causes…

Alaska Airlines

Our challenge was to further improve the medication administration process at our facility by proactively…

Jackson County Memorial Hospital
Contact Us