Root Cause Tip: What is “Behavior” and is it a “Cause” of an Accident?

Posted: March 13th, 2013 in Accidents, Human Performance, Performance Improvement, Root Cause Analysis Tips, Root Causes

Here’s the Meridian-Webster On-line Dictionary definition of “behavior”:

1. a : the manner of conducting oneself
    b : anything that an organism does involving action and response to stimulation
    c : the response of an individual, group, or species to its environment
2 : the way in which someone behaves; also : an instance of such behavior
3 : the way in which something functions or operates

Another definition that I think that management has in their heads is a “behavior” is:

“Any action or decision that an employee makes that management,
after the fact, decides was wrong.”

Why do I say that mangement uses this definition? Because I often hear about managers blaming the employee’s bad behavior for an accident.

For example, the employee was hurrying to get a job done and makes a mistake. That’s bad behavior!

What if an employee doesn’t hurry? Well, we yell at them to get going!

And what if they hurry and get the job done without an accident? We reward them for being efficient and a “go-getter.”

Management doesn’t usually see their role in making a “behavior” happen.

Behavior should NEVER be the end of a root cause analysis. Behavior is a fact. Just like a failed engine is a fact when a race car “blows it’s engine.”

Of course, a good root cause analysis should look into the causes for a behavior (a mistake) and uncover the reasons for the mistake and, if applicable, the controls that management has over behavior and how those controls failed when an accident occurred.

A bad decision or a human error that we call a “behavior” isn’t the end of the investigation … it is just the beginning!

TapRooT® helps investigator go beyond the symptoms (the behaviors) and find the root causes that management can fix. Some of the most difficult behaviors to fix are those so ingrained in the organization that people can’t see any other way to work.

For example, the culture of cost saving/cutting at BP was so ingrained, that even after the explosions and deaths at the Texas City Refinery, BP didn’t (couldn’t?) change it’s culture – at least not in the Gulf of Mexico exploration division – before they had the Deepwater Horizon accident. At least that is what I see in the reports and testimony that I’ve reviewed after the accident.

And with smaller incidents, it is even harder to get some managers’ attention and show them how they are shaping behavior. But at least in TapRooT® tries by providing guidance in analyzing human errors that leads to true root causes (not just symptoms).

Want to find out more about TapRooT® and behavior? Attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Courses. You’ll see how TapRooT® helps you analyze behavior issues in the exercises on the second day of the training. And you will learn much more. For a public 5-Day Course near you see:

Cool Video about Cut Resistant Gloves

Posted: March 7th, 2013 in Human Performance, Video


CLICK HERE to go to their web site to see more videos and order gloves.

Mark Paradies Speaks at 2013 IOSH Conference

Posted: February 27th, 2013 in Accidents, Current Events, Human Performance, Investigations, Performance Improvement, Presentations

Mark gave two well received talks at the 2013 IOSH Conference in London.

Because of the many requests for copies of his talks (Deepwater Horizon & Texas City … Three Lessons You May NOT Have Learnt and The Safety Pyramid & Stopping Major Accidents), PDFs of the talks are posted below.



Quick Idea … Value of Life Influences Safety Standards

Posted: February 15th, 2013 in Human Performance

Does the value you place on life influence the national health & safety standards vs the risk the government allows?

Health & Safety Standards = f(Value of Life-Risk Allowed)

Mark Paradies Speaking at the IOSH Conference

Posted: February 12th, 2013 in Human Performance, Performance Improvement, Presentations


Mark Paradies, President of System Improvements and co-creator of the TapRooT® System, will be speaking at the IOSH Conference in Spotlight Theatre 2 on Tuesday, February 26, and Wednesday, February 27.

His topics are:

Tuesday: 13:20 – 13:50 – Spotlight Theatre 2
BP Deepwater Horizon & BP Texas City Accidents: Two Lessons That You May NOT Have Learned

Much has been published about the BP Deepwater Horizon and Texas City Refinery accidents. But there are still some important lessons learned that people may be overlooking. Mark Paradies, root cause analysis expert, will share insights into two lessons learned that have not received much attention yet are important to safety improvement.

Wednesday: 11:20-11:50 – Spotlight Theatre 2

Fixing The Safety Pyramid & Stopping Major Accidents

Several articles have been published criticizing Heinrich’s Safety Pyramid and blaming it’s weaknesses for the gap between the decline in safety statistics and the continuing level rate of serious injuries, including fatalities. Mark Paradies will share insight into the Safety Pyramid and explain why fatality prevention needs a revised model and new approaches to achieve across the board safety performance improvements.

Hope to see you there!

Monday Accident & Lessons Learned: Fastest Way to Get Into Trouble

Posted: February 4th, 2013 in Human Performance, Performance Improvement

This lesson learned is from a regulatory incident.

I remember talking to a nuclear industry VP who had a troubled plant (NRC regulatory issues). He said that he was blindsided by their problems. It was as if the day before he was walking along on a beautiful day and the next morning he woke up at the bottom of a deep dark hole. The change seemed almost instantaneous … without warning.

How does a leading company go from excellence to disaster? It isn’t that there weren’t warning signs. The signs were there but management missed them.

The fastest way to get in trouble is to start thinking that you are so good that you don’t need to pay attention to small problems. That you can economize on improvement without experiencing performance improve-ment declines. That your cost saving efforts will NOT lead to field personnel placing more emphasis on production and less on safety and quality.

The switch from a performance improvement focus to a cost-cutting focus can seem like a small change – a minor variation. But when the problems start – when you wake up at the bottom of the deep dark hole – you will say the same thing that the nuclear VP said:

If I’d known how bad
this was going to be,
I would have paid any
amount of money to avoid it.

Don’t find yourself at the bottom of the deep dark hole.

Keep your focus on performance improvement.

Learn best practices that others use to make their programs better every year.

Where can you learn these practices? At the 2013 Global TapRooT® Summit in Gatlinburg, TN!

Summit week is March 18-22. Register now to ensure your choice of the pre-Summit Courses.

Get complete Summit info including the complete Summit schedule at:

Remember, there is no time like the present to avoid a disaster!

Monday Motivation: Fitness Advice to Lose Weight – Get Motivated!

Posted: January 14th, 2013 in Human Performance, Performance Improvement, Video

He says you will “Jump out of your chair!”…

He’s a Tony Robbins Fan.

TapRooT® Holiday Safety Tips Part II

Posted: December 17th, 2012 in Current Events, Human Performance, Pictures, Root Cause Analysis Tips, Video

Last week we shared some quick tips and staggering stats on Fall Safety and Electrical Safety during the holiday season. Here are a few tips from The Electrical Safety Foundation International to keep you and your children safe when displaying your decorations.

Fire Safety

  1. Make sure your Christmas tree is fresh, and keep it hydrated by refilling the stand. It will pose less of a fire hazard this way.
  2. With artificial trees, look for a fire resistant one.
  3. Don’t use electrical ornaments or lights on trees with metallic leaves or tinsel in them.
  4. Place your tree at least 3 feet away form heat sources, including fireplaces, radiators, and heaters.
  5. 45% of home décor fires start with candles.
  6. An average of 260 homes fires begin with Christmas trees each year, resulting in 12 deaths, 24 injuries, and $16.4 million in damage.

Check out this Fire safety video comparing the flammability of a poorly watered tree and properly watered tree: Click Here

Child Safety

  1. Keep children supervised around candles and electrical lights.
  2. Never allow them to use garlands, tree lights, and cords as playthings – they pose a strangulation hazard.
  3. All small, fragile ornaments and decorations should be placed out of children’s reach, as children may break them and get hurt, or simply put them in their mouth.
  4. Cover all unused outlet with electrical tape or plastic covers.

Happy Holidays and stay safe, from all of us at TapRooT®!

Photo 1 2

Click here to read Part 1!

Monday Motivation: Links on Motivation

Posted: November 26th, 2012 in Career Development, Career Development Tips, Human Performance, Performance Improvement listed links to what they think are the best tips for motivating employees.  The article asserts:

” … success of any facet of your business can almost always be traced back to motivated employees. From productivity and profitability to recruiting and retention, hardworking and happy employees lead to triumph.”

Links to articles on motivation listed fall into categories ranging from changing corporate culture to non-cash incentives to creating a fun workplace and more.

See the link below and make some positive resolutions for enhancing motivation in your workplace:

Why Can’t We Get Beyond Blame?

Posted: October 19th, 2012 in Current Events, Human Performance, Root Causes

R.R. Donnelley & Sons Co. prematurely filed Google Inc.’s earnings report with the Securities and Exchange Commission on Thursday.  Google’s earnings were supposed to be released after the stock markets closed at 3 p.m. Instead, they showed up on the SEC’s Edgar website about 11:30 a.m.  Google’s stock dropped as much as 11 percent, to $676 a share, before trading was halted about 20 minutes later at the company’s request.

About an hour after the earnings release, Google issued a statement blaming Chicago-based R.R. Donnelley for the blunder.

(“Glitch on Google Earnings Report under Investigation,” Chicago Tribune, October 19, 2012.)

Why do people think that blame will stop incidents? Haven’t we tried that already? Don’t the incidents just continue? Share your comments below.

Monday Accident & Lessons Learned: Truck Accident

Posted: October 8th, 2012 in Accidents, Current Events, Human Performance, Investigations, Performance Improvement

Sent by a concerned TapRooT® User …

Lessons Learnt 2012.08.23 Fuel Truck Turnover Eng
(Click to read full sized.)

Monday Motivation: 9 Things That Motivate Employees More Than Money

Posted: October 8th, 2012 in Career Development, Career Development Tips, Human Performance, Performance Improvement, Pictures

 Uploaded Files Image Dancing-Employees-Pop 11910

Inc. Magazine published a story about the “9 Things That Motivate Employees More Than Money”. Here’s the list:

1. Be generous with praise.

2. Get rid of the managers.

3. Make your ideas theirs.

4. Never criticize or correct.

5. Make everyone a leader.

6. Take an employee to lunch once a week.

7. Give recognition and small rewards.

8. Throw company parties.

9. Share the rewards—and the pain.

See the complete story at:

What do you think? Good ideas?

Do You Have a Fatigue Risk Management Program?

Posted: October 5th, 2012 in Human Performance

One of the things that was discussed at the 2012 Global TapRooT® Summit was fatigue risk management programs. Just thought I’d pass along to readers that Circadian Technologies is having a public course titled:

Developing & Implementing an Effective Fatigue Risk Management System

on November 7-8, 2012, in New Orleans. See the brochure below or click on this link for more info …

Circadian - Frms Seminar Brochure - New Orleans 2012

Press Release on Fatigue from Circadian Technologies

Posted: October 4th, 2012 in Human Performance

CIRCADIAN Presents a Complimentary White Paper:

The Definition of Human Fatigue
by Martin Moore-Ede, M.D., Ph.D.

Everyone these days is talking about employee fatigue, driver fatigue and fatigue risk management systems. But what exactly is the definition of “fatigue”?
While engineers use the term to describe the irreversible failure of materials as a result of stresses over an extended period of time, the term is also used to describe human impairment in the workplace or on the highway.

In The Definition of Human Fatigue, Dr. Moore-Ede, one of the world’s leading experts on human fatigue, explains the meaning of fatigue and its causes, including extended wakefulness, heavy work, excessive stimulation, illness or stress. Knowing what exactly is meant by human fatigue is critical to reversing it.

Download the White Paper:
“The Definition of Human Fatigue”

CIRCADIAN offers its white papers for free to shift work managers and others interested in improving the health, safety and productivity of the 24/7 workforce.

Throughout our 29 years of working with shiftwork and extended hours operations, CIRCADIAN has written many white papers in response to our clients questions and interests. If you have a question for us, please contact us.

For a complete list of our white papers, please click here.

Two Main Street, Suite 310
Stoneham, MA 02180 USA

Phone) 781-439-6300

Have You Saved a Life Today?

Posted: October 3rd, 2012 in Human Performance, Performance Improvement, Pictures, TapRooT

When was the last time you saved a life?

I remember the first time I saw my daughter, who had a summer job as a lifeguard, save a man and a boy from drowning in a lake. Afterwards I talked to her. She didn’t see it as a big deal. She said she did rescues every week. She didn’t consider it heroic. It was just part of her job.

Several years ago at the TapRooT® Summit, a TapRooT® User approached me to thank me. He said that they had stopped fatalities at their site after learning to apply TapRooT®. He told me that improved performance meant that, over a period of several years, they had saved about five lives at their refinery. He then said …

“Imagine how many TapRooT® Users there are applying TapRooT® around the world …
Easily there are hundreds of lives saved every year!”

Have you found and fixed the root causes of potentially fatal accidents at your site? Then you too have saved a life – or maybe more than one life.

Try not to become complacent about the lives you are saving. Celebrate your success. Tell others about the good job they are doing. Make sure that management knows about the lives saved.

And never stop improving. 

As my boss in the Navy, Captain Willian J. Rodriguez, told me:

“If you’re not pedaling, you’re going downhill.”


Don’t become complacent about saving lives.

Keep up the good work.

And when you can, enlist others in this great cause.

Monday Accident & Lessons Learned: Learning from Fatal Car Wrecks

Posted: September 17th, 2012 in Accidents, Human Performance, Performance Improvement

Consumer Reports published an article about teenage and older person fatality rates. They had this graph…

 Content Dam Cro Magazine-Articles 2012 October Consumer-Reports-Dangerous-Drivers-10-12

Here is something interesting that you can learn …

Did you know that the human brain doesn’t fully develop the ability to assess risk until about age 25? Now look at the graph above. Look at the fatality reduction post age 25.

Now think … what are you doing to keep your (<25) year old workers safe in all situations where they make make poor risk decisions?

In our family we did what the article recommended – a graduated driving program.

First, kids weren’t allowed to obtain their full licenses until they were 17.

Next, we talked to them extensively about the risk of driving before we let them start driving independently and kept that as limited as possible (no friends in the car – only family for the first year). We did a lot of “critiqued” driving with them even after they had their full license. We also had them take advanced (beyond high school drivers ed) classes put on by our local police.

And we didn’t get them high powered vehicles.

How could you take the same approach with young employees?

Monday Accident & Lessons Learned: UK RAIB Report on a Track Worker Struck by a Train at Stoats Nest Junction, 12 June 2011

Posted: August 27th, 2012 in Accidents, Current Events, Human Performance, Investigations

Here’s a link to a report by the UK Rail Accident Investigation Branch about a train that struck a worker near the tracks:

How do you keep your workers safe from moving vehicles?

One interesting point in this report was that the train’s horn probably could not be heard by the track workers because of the noise generated by the equipment they were using.

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