Category: Current Events

Strange Aviation Incident

August 16th, 2018 by

Imagine your corporate safety investigation of this…

Intelex and TapRooT® Partner to Offer In-Depth Root Cause Analysis

August 14th, 2018 by

In this video, hear about TapRooT®’s recent partnership with Intelex Technologies, a leading global provider of cloud-based Environmental, Health, Safety and Quality (EHSQ) management software. The integration of Intelex Technologies with TapRooT® allows customers to enter an injury in Intelex, perform a detailed root cause analysis using TapRooT®, and capture the result of the root cause analysis within Intelex. Customers are able to leverage Intelex’s powerful reporting and analytics foresight on injury and root cause data, ultimately producing better decisions and reducing the risk of repeat incidents, injuries and illnesses. The integration will also remove the administrative and record keeping hassle of managing two disparate incident and root cause analysis tools.

About the partnership, TapRooT®’s Vice President and Chief Technology Officer Dan Verlinde said, “We’re excited to establish a partnership with Intelex. TapRooT® and Intelex both create safer work places and help companies achieve operational excellence—that’s why this was an obvious opportunity to collaborate. This partnership will allow our joint customers to realize an integrated Environmental Health and Safety and Root Cause Analysis solution, while reducing duplicate effort.” And, Kristen Duda, Vice President, Strategic Alliances and Partnerships at Intelex, observed of the new integration, “This partnership provides customers with an industry-leading, integrated solution for taking their injury and root cause analysis data to the next level. By leveraging Intelex and TapRooT®, customers can drive impactful proactive safety decisions.”

Connect with us on Wednesdays for TapRooT®’s Facebook Live:


What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

What’s Wrong with Pharmaceutical Root Cause Analysis?

August 8th, 2018 by


I was forwarded a copy of an interesting letter about American and Canadian Standards Boards with certifying bodies rejecting pharmaceutical quality incident reports because of poor root cause analysis. It stated that 90% of the rejections of reports were due to three types of root causes that were unacceptable (and I quote):

  1. Employee Error / Human Error / Operator Error OR anyone else who made an error is not an acceptable root cause – Was the training ineffective?  Was the procedure too vague?
  2. Misunderstood the requirement / Did not know it was a requirement / Our consultant told us this was ok OR any other misunderstandings is not an acceptable root cause.  Was the training effective?
  3. We had a layoff / Mona was on maternity leave / we moved locations / we scaled back production / we are still closing out Wayne’s 40 deviations from the last audit OR most other employee or business conditions are not acceptable root causes  They are DIRECT CAUSES.

The letter proposed four rules to follow with all future submissions:

  1. RULE #1:  The root cause can not be a re-statement of the deviation.  Example:  Deviation – Company XYZ did not document Preventive Actions as required by procedure.  Root Cause – We did not document Preventive Actions as required by the procedure.
  2. RULE #2:  There can not be an obvious “Why” that can be easily answered to the provided root cause – in this case they have not gone deep enough.  Example: Root Cause – The purchasing coordinator made a mistake and did not check to see if the supplier was approved.  Obvious “WHY” Was the training effective?  Did the procedure provide enough detail in this area?
  3. RULE #3:  The root cause can not be a direct cause.  Example:  Deviation – There were a number of internal audits scheduled for 2008 that were not completed.  Root Cause – We had a layoff and we did not have enough Internal Auditors to conduct the audits.
  4. RULE #4:  The root cause is a brief description of the cause of the problem.  We do not want any long stories regarding direct causes or what they are doing well even though this happened or who said what.  This is un-necessary detail and only adds confusion.

Wow! I would have thought this guidance would not be necessary. Are responses to quality incidents really this poor? Or is this letter a fake?

No wonder TapRooT® Users have no problem getting approvals for their root cause analysis. None of these problems would happen with any investigation using TapRooT®.

Why would TapRooT® Users never stop at the three causes listed above? Because they would understand that some are Causal Factors (the start of the root cause analysis) and they would have guidance provided by the Root Cause Tree® Diagram to help them find the real, fixable root causes of human performance and equipment failure related problems. This includes analyzing things like “internal audits not completed”; “human error”; and “misunderstood requirements.”

In addition, the TapRooT® Software helps investigators develop concise custom reports that only includes the details needed to understand what happened, how it happened, the root causes, and the effective corrective actions needed to prevent recurrence.

If you are in the pharmaceutical industry and you want to stop having problems with root cause analysis and want to start having effective investigations, root cause analysis, and fixes for problems, attend our TapRooT® Training and learn how simple advanced root cause analysis is.

Monday Accidents & Lessons Learned: When One Good Turn Definitely Doesn’t Deserve Another

July 16th, 2018 by

The electronic flight bag (EFB) is rapidly replacing pilots’ conventional papers in the cockpit. While the EFB has demonstrated improved capability to display aviation information—airport charts, weather, NOTAMs, performance data, flight releases, and weight and balance—NASA’s Aviation Safety and Reporting System (ASRS) has received reports that describe various kinds of EFB anomalies, such as this one:

“This B757 Captain received holding instructions during heavy traffic. While manipulating his EFB for clarification, he inadvertently contributed to an incorrect holding entry.

‘[We were] asked to hold at SHAFF intersection due to unexpected traffic saturation. While setting up the FMC and consulting the arrival chart, I expanded the view on my [tablet] to find any depicted hold along the airway at SHAFF intersection. In doing so, I inadvertently moved the actual hold depiction…out of view and [off] the screen.

‘The First Officer and I only recall holding instructions that said to hold northeast of SHAFF, 10-mile legs. I asked the First Officer if he saw any depicted hold, and he said, “No.” We don’t recall instructions to hold as depicted, so not seeing a depicted hold along the airway at SHAFF, we entered a right-hand turn. I had intended to clarify the holding side with ATC, however there was extreme radio congestion and we were very close to SHAFF, so the hold was entered in a right-hand turn.

‘After completing our first 180-degree turn, the controller informed us that the hold at SHAFF was left turns. We said that we would correct our holding side on the next turn. Before we got back to SHAFF for the next turn, we were cleared to [the airport].'”

Volpe National Transportation Systems Center, U.S. Department of Transportation, weighs in on EFBs: “While the promise of EFBs is great, government regulators, potential customers, and industry developers all agree that EFBs raise many human factors considerations that must be handled appropriately in order to realize this promise without adverse effects.”

CALLBACK is the award-winning publication and monthly safety newsletter from NASA’s Aviation Safety Reporting System (ASRS). CALLBACK shares reports, such as the one above, that reveal current issues, incidents, and episodes.

Circumstances can crop up anywhere at any time if proper sequence and procedures are not planned and followed. We encourage you to learn and use the TapRooT® System to find and fix problems. Attend one of our courses. We offer a basic 2-Day Course and an advanced 5-Day Course. You may also contact us about having a course at your site.

Monday Accident & Lessons Learned: Fatal Accident While Unloading a Truck

July 9th, 2018 by

WKBW TV reported that two employees were killed when a stack of Corian counter tops that weighed 800 pounds per slab (11 slabs total) fell on them. The accident occurred at 1:30 a.m. and the employees were pronounced dead at the scene.

The company issued a statement that said:

“We’re saddened to report that a tragic accident occurred this morning at our facility in Lockport, NY that resulted in the death of two of our colleagues. We’re working with our safety team and local law enforcement to understand the circumstances under which this tragedy occurred. Our deepest sympathies are with their families and our Lockport team members.”

OSHA will be conducting an investigation of the deaths. OSHA has investigated two other serious injuries at XPO facilities elsewhere in New York state.

What was the Hazard in this accident?

The heavy, high-piled load.

Who were the targets?

The two employees.

What were the Safeguards?

From the newspaper articles, we don’t know.

We also don’t know any of the reasons for the Safeguard’s failure.

The root cause analysis will have to determine the Safeguards, why they failed, and if they were sufficient. (Do we need additional Safeguards?)

In the TapRooT® System, a SnapCharT® would be used to collect and organize the information about what happened.

Then the failed Safeguards would be identified.

Next, the failed Safeguards (Causal Factors) would be analyzed to find their root causes using the Root Cause Tree® Diagram.

Once the root causes for all the Safeguards were found, the team would start developing corrective actions.

The Safeguards would be reviewed to see if after they were strengthened, if they would be adequate. If they would not be adequate, either additional Safeguards would be developed or the process could be modified to reduce or remove the hazard. For example, stack the counter tops no more that 16 inches high.

To improve the Safeguards that failed, you would address each of the root causes by developing SMARTER corrective actions using the Corrective Action Helper® Module of TapRooT® Software.

What is a SMARTER corrective action?








To learn more about the TapRooT® System, SnapCharT®, Safeguard Analysis, Causal Factors, the Root Cause Tree® Diagram, the Corrective Action Helper® Module, the TapRooT® Software, and SMARTER, attend one of our 2-Day or 5-Day TapRooT® Courses. Here is a list of the dates and locations of the courses being held around the world:

Happy 4th of July

July 4th, 2018 by


In the US we celebrate declaring our independence from The British crown on the 4th of July. It was a great risk for a minor colony to stand up to the world’s mightiest power. Perhaps were were foolish or you might say reckless … but the outcome was a system without a king and with a constitution that affirmed and guaranteed our God given rights.

So today when you are celebrating somewhere in the US, remember those who risked all for the freedoms we enjoy today and those who stand ready to do that today.

Happy Independence Day!

One Safeguard Eliminated = Death

July 3rd, 2018 by

Watch the video and see what could have been done to avoid a fatality…

I think there was an obvious Safeguard missing. What was it?

Monday Accidents & Lessons Learned: Where Did We Put the Departure Course?

July 2nd, 2018 by

Have you ever encountered a new methodology or product that you deemed the best thing ever, only to discover in a too-close-for-comfort circumstance that what seemed a game changer had a real downside?

In aviation, the Electronic Flight Bag (EFB) is the electronic equivalent to the pilot’s traditional flight bag. It contains electronic data and hosts EFB applications, and it is generally replacing the pilots’ conventional papers in the cockpit. The EFB has demonstrated improved capability to display aviation information such as airport charts, weather, NOTAMs, performance data, flight releases, and weight and balance.

The EFB platform, frequently a tablet device, introduces a relatively new human-machine interface into the cockpit. While the EFB provides many advantages and extensive improvements for the aviation community in general and for pilots specifically, some unexpected operational threats have surfaced during its early years.

NASA’s Aviation Safety and Reporting System (ASRS) has received reports that describe various kinds of EFB anomalies. One typical problem occurs when a pilot “zooms,” or expands the screen to enlarge a detail, thereby unknowingly “slides” important information off the screen, making it no longer visible.

An Airbus A320 crew was given a vector to intercept course and resume the departure procedure, but the advantage that the EFB provided in one area generated a threat in another.

From the Captain’s Report:

“Air Traffic Control (ATC) cleared us to fly a 030 heading to join the GABRE1 [Departure]. I had never flown this Standard Instrument Departure (SID). I had my [tablet] zoomed in on the Runway 6L/R departure side so I wouldn’t miss the charted headings. This put Seal Beach [VOR] out of view on the [tablet]. I mistakenly asked the First Officer to sequence the Flight Management Guidance Computer (FMGC) between GABRE and FOGEX.”

From the First Officer’s Report:

“During our departure off Runway 6R at LAX [while flying the] GABRE1 Departure, ATC issued, ‘Turn left 030 and join the GABRE1 Departure.’ This was the first time for both pilots performing this SID and the first time departing this runway for the FO. Once instructed to join the departure on the 030 heading, I extended the inbound radial to FOGEX and inserted it into the FMGC. With concurrence from the Captain, I executed it. ATC queried our course and advised us that we were supposed to intercept the Seal Beach VOR 346 radial northbound. Upon review, both pilots had the departure zoomed in on [our tablets] and did not have the Seal Beach [VOR] displayed.”

CALLBACK is the award-winning publication and monthly safety newsletter from NASA’s Aviation Safety Reporting System (ASRS). CALLBACK shares reports, such as the one above, that reveal current issues, incidents, and episodes.

Circumstances can crop up anywhere at any time if proper sequence and procedures are not planned and followed. We encourage you to learn and use the TapRooT® System to find and fix problems. Attend one of our courses. We offer a basic 2-Day Course and an advanced 5-Day Course. You may also contact us about having a course at your site.

Monday Accident & Lessons Learned: What Does a Human Error Cost? A £566,670 Fine in the UK!

June 25th, 2018 by

Dump truck(Not actual truck, For illustration only.)

The UK HSE fined a construction company £566,670 after a dump truck touched (or came near) a power line causing a short.

No one was hurt and the truck suffered only minor damage.

The drive tried to pull forward to finish dumping his load and caused a short.

Why did the company get fined?

“A suitable and sufficient assessment would have identified the need to contact the Distribution Network Operator, Western Power, to request the OPL’s were diverted underground prior to the commencement of construction. If this was not reasonably practicable, Mick George Ltd should have erected goalposts either side of the OPL’s to warn drivers about the OPL’s. “

That was the statement from the UK HSE Inspector as quoted in a hazarded article.

What Safeguards do you need to keep a simple human error from becoming an accident (or a large fine)?

Performing a Safeguard Analysis before starting work is always a good idea. Learn more about using Safeguard Analysis proactively at our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. See the upcoming public course dats around the world at:

Integrating TapRooT® with Enablon EHS Software

June 22nd, 2018 by

As TapRooT® professional Benna Dortch says, “In today’s busy world, we get so much more done if we work seamlessly together.”

TapRooT®’s partnership with Enablon, the world’s leading provider of sustainability, EHS, and operational risk management software, is a great example of seamless collaboration through software integration and implementation, achieved by the technology teams of both companies.

Earlier this month, TapRooT® was recognized as Enablon’s Technology Partner of the Year, awarded to “the partner with innovative technological solutions that has successfully integrated its solutions with the Enablon platform to increase value for Enablon clients.” Take a further look at Enablon and the Enablon Excellence Awards in the below article.

5 Companies Recognized for Excellence at SPF EMEA 2018

In this Facebook Live session, you will learn more about global leader Enablon and what it does, and the interface between Enablon and TapRooT®.

Integrating TapRooT® with Enablon EHS Software from TapRooT® Root Cause Analysis on Vimeo.

TapRooT® is the best method for performing investigations and doing root cause analysis. TapRooT® Training Courses are designed to further your professional development and help you in your investigations and corrective actions. We’re happy to come to your workplace to teach your team onsite, just let us know or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

TapRooT® Collaboration With Intelex Provides Users With A Better Root Cause Analysis Tool

June 20th, 2018 by

TapRooT® is pleased to announce our partnership with Intelex Technologies!

So, what does this mean for TapRooT® users? Click here to learn more about Intelex, and how the partnership will help you make better decisions and reduce the risk of repeat incidents, injuries, and illnesses.

“We’re excited to establish a partnership with Intelex. TapRooT and Intelex both create safer workplaces and help companies achieve operational excellence, that’s why this was an obvious opportunity to collaborate.” – Dan Verlinde VP and CTO

Monday Accident & Lessons Learned: Why is Right of Way Maintenance Important?

June 18th, 2018 by

Here is another example of why right of way maintenance is important for utility transmission and distribution departments …


An article on hazardex reported that the California Department of Forestry and Fire Protection (Cal Fire) said in a press release that 12 of the wildfires that raged across California’s wine country were due to tree branches touching PG&E power lines.

Eight of the 12 fires have been referred to county District Attorney’s offices for potential criminal prosecution for alleged violations of California laws.

The fires last October killed 44 people, burned more than 245,000 acres, and cost at least $9.4 billion dollars of insured losses. PG&E has informed it’s shareholders that it could be liable costs in excess of the $800 million in insurance coverage that it has for wildfires.

PG&E is lobbying state legislators for relief because they are attributing the fires to climate change and say they should not be held liable for the damage.

What lessons can you learn from this?

Sometimes the cost of delayed maintenance is much higher than the cost of performing the maintenance.

Can you tell which maintenance is safety critical?

Do you know the risks associated with your deferred maintenance?

Things to think about.

Will you be at the Safety & Health Expo in London next week?

June 11th, 2018 by

If so, please stop by the TapRooT® Stand (N165) and say hello. Per Ohstrom and Hans Kleppan will be there to tell you all about TapRooT®. They also have a special gift for you (while supplies last)!

New Study Suggests Poor Officer Seamanship Training Across the Navy – Is This a Generic Cause of 2017 Fatal Navy Ship Collisions?

June 7th, 2018 by


It is hard to do a root cause analysis from afar with only newspaper stories as your source of facts … but a recent The Washington Times article shed some light on a potential generic cause for the fatal collisions last year.

The Navy conducted an assessment of seamanship skills of 164 first-tour junior officers. The results were as follows

  • 16% (27 of 164) – no concerns
  • 66% (108 of 164) – some concerns
  • 18% (29 of 164) – significant concerns

With almost 1 out of 5 having significant concerns, and two thirds having some concerns, it made me wonder about the blame being placed on the ship’s Commanding Officers and crew. Were they set up for failure by a training program that sent officers to sea who didn’t have the skills needed to perform their jobs as Officer of the Deck and Junior Offiicer of the Deck?

The blame heavy initial investigations certainly didn’t highlight this generic training problem that now seems to be being addressed by the Navy.

Navy officers who cooperated with the Navy’s investigations faced court martials after cooperating.


According to and article in The Maritime Executive Lt j.g. Sarah Coppock, Officer of the Deck during the USS Fitzgerald collision, pled guilt to charges to avoid facing a court martial. Was she properly trained or would have the Navy’s evaluators had “concerns” with her abilities if she was evaluated BEFORE the collision? Was this accident due to the abbreviated training that the Navy instituted to save money?

Note that in the press release, information came out that hadn’t previously been released that the Fitzgerald’s main navigation radar was known to be malfunctioning and that Lt. j.g. Coppock thought she had done calculations that showed that the merchant ship would pass safely astern.


In other blame related news, the Chief Boatswains Mate on the USS McCain plead guilty to dereliction of duty for the training of personnel to use the Integrated Bridge Navigation System, newly installed on the McCain four months before he arrived. His total training on the system was 30 minutes of instruction by a “master helmsman.” He had never used the system on a previous ships and requested additional training and documentation on the system, but had not received any help prior to the collision.

He thought that the three sailors on duty from the USS Antietam, a similar cruiser, were familiar with the steering system. However, after the crash he discovered that the USS McCain was the only cruiser in the 7th fleet with this system and that the transferred sailors were not familiar with the system.

On his previous ship Chief Butler took action to avoid a collision at sea when a steering system failed during an underway replenishment and won the 2014 Sailor of the Year award. Yet the Navy would have us believe that he was a “bad sailor” (derelict in his duties) aboard the USS McCain.


Also blamed was the CO of the USS McCain, Commander Alfredo J. Sanchez. He pleaded guilty to dereliction of duty in a pretrial agreement. Commander Sanchez was originally charged with negligent homicide and hazarding a vessel  but both other charges were dropped as part of the pretrial agreement.

Maybe I’m seeing a pattern here. Pretrial agreements and guilty pleas to reduced charges to avoid putting the Navy on trial for systemic deficiencies (perhaps the real root causes of the collisions).

Would your root cause analysis system tend to place blame or would it find the true root and generic causes of your most significant safety, quality, and equipment reliability problems?

The TapRooT® Root Cause Analysis System is designed to look for the real root and generic causes of issues without placing unnecessary blame. Find out more at one of our courses:

TapRooT® wins Technology Partner of the Year

June 7th, 2018 by

TapRooT® Root Cause Analysis Software is used by leading companies around the world.

Ken Reed and Dan Verlinde are attending 2018 SPF EMEA 2018 in Paris, France this week where TapRooT® was recognized as Technology Partner of the Year. TapRooT® Software is developed to manage, measure and report TapRooT® Root Cause Analysis investigations.  We’re very proud to be part of an exceptional team of people who are committed to excellence in everything they do.

Learn more about the award here.

Learn about why TapRooT® Root Cause Analysis Software is the best choice here.

ASSE (Safety 2018) is almost here!

May 22nd, 2018 by

The best safety conference of the year. I can’t wait.

If you are attending the conference, please stop by and see us at booth 843. Barb and I will be there. The first 500 people will get a special gift, so don’t miss out!

See you in San Antonio!

Thanks to all my Linkedin Connections

May 22nd, 2018 by

I have reached 20,000 Linkedin connections! Thank you for your support!

If we are not yet connected, please send me a REQUEST

Newest Aircraft Carrier Breaks Down During Sea Trials

May 8th, 2018 by

USS Ford underway for sea trials …

An article in Popular Mechanics said the the USS Ford had to return early from sea trials because of an overheating thrust bearing on one of the four main engines. Bloomberg reported that:

“inspection of the parts involved in the January 2018 incident revealed improperly machined gears at GE’s facility in Lynn, Massachusetts as the ‘root cause.'”

Is “improperly machined gears” a root cause? That would be a Causal Factor and the start of a root cause analysis in the TapRooT® System. And why wasn’t the “improper” machining detected prior to installation and sea trials?

Here is some footage of sea trials (including a brief glimpse of one main shaft turning).

Hazards and Targets

May 7th, 2018 by

Most of us probably would not think of this as a on the job Hazard … a giraffe.

Screen Shot 2018 05 07 at 9 40 49 AM

But African filmmaker Carlos Carvalho was killed by one while working in Africa making a film.

Screen Shot 2018 05 07 at 9 42 38 AM

 Do you have unexpected Hazards at work? Giant Asian hornets? Grizzly bears? 

Or are your Hazards much more common. Heat stroke. Slips and falls (gravity). Traffic.

Performing a thorough Safeguard Analysis before starting work and then trying to mitigate any Hazards is a good way to improve safety and reduce injuries. Do your supervisors know how to do a Safeguard Analysis using TapRooT®?

Press Release: CSB to Investigate Husky Refinery Fire

April 26th, 2018 by


Washington, DC, April 26, 2018 –  A four-person investigative team from the U.S. Chemical Safety Board (CSB) is deploying to the scene of an incident that reportedly injured multiple workers this morning at the Husky Energy oil refinery in Superior, Wisconsin. The refinery was shutting down in preparation for a five-week turnaround when an explosion was reported around 10 am CDT.

According to initial reports, several people were transported to area hospitals with injuries. There have been no reports of fatalities. Residents and area schools near the refinery were asked to evacuate due to heavy smoke.

The CSB is an independent, non-regulatory federal agency charged with investigating serious chemical incidents. The agency’s board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.

The Board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA. Visit the CSB website,

Here is additional coverage of the fire …


Monday Accidents & Lessons Learned: Putting Yourself on the Right Side of Survival

April 23rd, 2018 by

While building an embankment to circumvent any material from a water supply, a front end loader operator experienced a close call. On March 13, 2018, the operator backed his front end loader over the top of a roadway berm; the loader and operator slipped down the embankment; and the loader landed turning over onto its roof. Fortunately, the operator was wearing his seat belt. He unfastened the seat belt and escaped the upside-down machine through the broken right-side window of the loader door.

Front end loaders are often involved in accidents due to a shift in the machine’s center of gravity. The U.S. Department of Labor Mine Safety and Health Administration (MSHA) documented this incident and issued the statement and best practices below for operating front end loaders.

The size and weight of front end loaders, combined with the limited visibility from the cab, makes the job of backing a front end loader potentially hazardous. To prevent a mishap when operating a front end loader:
• Load the bucket evenly and avoid overloading (refer to the load limits in the operating manual). Keep the bucket low when operating on hills.
• Construct berms or other restraints of adequate height and strength to prevent overtravel and warn operators of hazardous areas.
• Ensure that objects inside of the cab are secured so they don’t become airborne during an accident.
• ALWAYS wear your seatbelt.
• Maintain control of mobile equipment by traveling safe speeds and not
overloading equipment.

We would add the following best practices for loaders:
• Check the manufacturer’s recommendations and supplement appropriate wheel ballast or counterweight.
• Employ maximum stabilizing factors, such as moving the wheels to the widest setting.
• Ensure everyone within range of the loader location is a safe distance away.
• Operate the loader with its load as close to the ground as possible. Should the rear of the tractor tip, its bucket will hit the ground before the tractor tips.

Use the TapRooT® System to put safety first and to solve problems. Attend one of our courses. We offer a basic 2-Day Course and an advanced 5-Day Course. You may also contact us about having a course at your site.

Mark Paradies Speaks about Root Cause Analysis at the Gas Processor’s Association

April 16th, 2018 by

Screen Shot 2018 04 16 at 11 29 20 AM

Attending the GPA Conference in Austin?

Then attend the Safety Committee Meeting on Tuesday (1:30 – 5:30) and hear Mark Paradies talk about common root cause analysis problems and how you can solve them.

Monday Accidents & Lessons Learned: When Retrofitting Does Not Evaluate Risks

April 9th, 2018 by

Bound for London Waterloo, the 2G44 train was about to depart platform 2 at Guildford station. Suddenly, at 2:37 pm, July 7, 2017, an explosion occurred in the train’s underframe equipment case, ejecting debris onto station platforms and into a nearby parking lot. Fortunately, there were no injuries to passengers or staff; damage was contained to the train and station furnishings. It could have been much worse.

The cause of the explosion was an accumulation of flammable gases within the traction equipment case underneath one of the train’s coaches. The gases were generated after the failure of a large electrical capacitor inside the equipment case; the capacitor failure was due to a manufacturing defect.

Recently retrofitted with a modern version of the traction equipment, the train’s replacement equipment also included the failed capacitor. The project team overseeing the design and installation of the new equipment did not consider the risk of an explosion due to a manufacturer’s defect within the capacitor. As a result, there were no preventative engineering safeguards.

The Rail Accident Investigation Branch (RAIB) has recommended a review of the design of UK trains’ electric traction systems to ensure adequate safeguards are in place to offset any identified anomalies and to prevent similar explosions. Learn about the six learning points recommended by the RAIB for this investigation.

Use the TapRooT® System to solve problems. Attend one of our courses. We offer a basic 2-Day Course and an advanced 5-Day Course. You may also contact us about having a course at your site.

McD’s in UK Fined £200k for Employee Injured While Directing Traffic

March 27th, 2018 by


An angry motorist hits a 17-year-old employee who is directing traffic and breaks his knee. Normally, you would think the road rage driver would be at fault. But a UK court fined McDonalds $200,000.

Why? It was a repeat incident. Two previous employees had been hurt while directing traffic. And McDonalds didn’t train the employees how to direct traffic.

What do you think? Would a good root cause analysis of the previous injuries and effective corrective actions have prevented this accident?

Is Having the Highest Number of Serious Incidents Good or Bad?

March 6th, 2018 by


I read an interesting article about two hospitals in the UK with the highest number of serious incidents.

On the good side, you want people to report serious incidents. Healthcare has a long history of under-reporting serious incidents (sentinel events).

On the good side, administrators say they do a root cause analysis on these incidents.

On the bad side, the hospitals continue to have these incidents. Shouldn’t the root cause analysis FIX the problems and the number of serious incidents be constantly decreasing and becoming less severe?

Maybe they should be applying advanced root cause analysis?

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®

Michelle WishounMichelle Wishoun

Licensing Paralegal

Per OhstromPer Ohstrom

VP, Sales

Shaun BakerShaun Baker

Technical Support

Steve RaycraftSteve Raycraft

Technical Support

Wayne BrownWayne Brown

Technical Support

Success Stories

Better Initial Information Collection Submitted by: Bill Missal, Senior Aviation Safety Inspector Company: FAA, Alaska Challenge Field investigators that, unfortunately, may not be trained in the use of TapRooT® collect initial information and then send it to trained investigators to analyze the root causes of aviation accidents using TapRooT®. The untrained field investigators may not …

Many of us investigate accidents that the cause seems intuitively obvious: the person involved…

ARCO (now ConocoPhillips)
Contact Us