Category: Investigations

Are you a Proficient TapRooT® Investigator?

March 19th, 2018 by








I teach a lot of TapRooT® courses all over the world, to many different industries and departments.  I often get the same questions from students during these courses.  One of the common questions is, “How do I maintain my proficiency as a TapRooT® investigator?”

This is a terrific question, and one that you should think carefully on.  To get a good answer, let’s look at a different example.:

Let’s say you’ve been tasked with putting together an Excel spreadsheet for your boss.  It doesn’t have to be anything too fancy, but she did ask that you include pivot tables in order to easily sort the data in multiple ways.  You decide to do a quick on-line course on Excel to brush up on the newest techniques, and you put together a great spreadsheet.

Now, if your boss asked you to produce another spreadsheet 8 months from now, what would happen?  You’d probably remember that you can use pivot tables, but you’ve probably forgotten exactly how it works.  You’ll most likely have to relearn the technique again, looking back over your last one, or maybe hitting YouTube as a refresher.  It would have been nice if you had worked on a few spreadsheets in the meantime to maintain the skills you learned from your first Excel course.  And what happens if Microsoft comes out with a new version of Excel?

Performing TapRooT® investigations are very similar.  The techniques are not difficult; they can be used by pretty much anyone, once they’ve been trained.  However, you have to practice these skills to get good at them and maintain your proficiency.  When you leave your TapRooT® course, you are ready to conduct your first investigation, and those techniques are still fresh.  If you wait 8 months before you actually use TapRooT®, you’ll probably need to refresh your skills.

In order to remain proficient, we recommend the following:

  • Obviously, you need to attend an initial TapRooT® training session.  We would not recommend trying to learn a technique by reading a book.  You need practice and guidance to properly use any advanced technique.
  • After your class, we recommend you IMMEDIATELY go perform an investigation, probably within the next 2 weeks or so.  You need to quickly use TapRooT® in your own work environment.  You need to practice it in your own conference room, know where your materials will be kept, know who you’re going to contact, etc.  Get the techniques ingrained into your normal office routine right away.
  • We then recommend that you use TapRooT® at least every month.  That doesn’t necessarily mean that you must perform a full incident investigation monthly, but maybe just use a few of the techniques.  For example, you could perform an audit and run those results though the Root Cause Tree®.  Anything to keep proficient using the techniques.
  • Refresher training is also a wonderful idea.  We would recommend attending a refresher course every 2 years to make sure you are up to speed on the latest software and techniques.  If you’ve attended a 2-Day TapRooT® course, maybe a 5-Day Advanced Team Leader Course would be a good choice.
  • Finally, attending the Annual Global TapRooT® Summit is a great way to keep up to speed on your TapRooT® techniques.  You can attend a specialized Pre-Summit course (Advanced Trending Techniques, or Equifactor® Equipment Troubleshooting, or maybe an Evidence Collection course), and then attend a Summit track of your choosing.

There is no magic here.  The saying, “Use it, or Lose it” definitely applies!

Miami Bridge Collapse – Is Blame Part of Your Investigation Policy?

March 16th, 2018 by

collapse miami bridge








I was listening to a news report on the radio this morning about the pedestrian bridge collapse in Miami. At one point, they were interviewing Florida Governor Rick Scott.  Here is what he said:

“There will clearly be an investigation to find out exactly what happened and why this happened…”

My ears perked up, and I thought, “That sounds like a good start to a root cause investigation!”

And then he continued:

“… and we will hold anybody accountable if anybody has done anything wrong,”

Bummer.  His statement had started out so good, and then went directly to blame in the same breath.  He had just arrived on the scene.  Before we had a good feel for what the actual circumstances were, we are assuming our corrective actions are going to pinpoint blame and dish out the required discipline.

This is pretty standard for government and public figures, so I wasn’t too surprised.  However, it got me thinking about our own investigations at our companies.  Do we start out our investigations with the same expectations?  Do we begin with the good intentions of understanding what happened and finding true root causes, but then have this expectation that we need to find someone to blame?

We as companies owe it to ourselves and our employees to do solid, unbiased incident investigations.  Once we get to reliable root causes, our next step should be to put fixes in place that answer the question, “How do we prevent these root causes from occurring in the future?  Will these corrective actions be effective in preventing the mistakes from happening again?”  In my experience, firing the employee / supervisor / official in charge rarely leads to changes that will prevent the tragedy from happening again.


ASSE Safety 2018 Flash Session on Investigative Interviewing

March 15th, 2018 by

I’m excited to be selected as a flash session speaker for ASSE Safety 2018. My talk “Top 3 Tips for Improving your Investigative Interviewing Skills” is planned for Monday, June 4, 2018 at 2:45 p.m. in the Exhibit Hall, Booth #2165. I hope to see you there! Please stop by the TapRooT® Booth and talk to Dave Janney and me while you’re at the conference.

Protection Against Hydrogen Sulfide

March 6th, 2018 by

On January 16, 2017, a private construction company sent four utility works to handle complaints about sewage backup in Key Largo, Florida. Three of the four works descended into the the 15-foot-deep drainage hole, and within seconds all voice communication was lost amongst the construction workers.

The Key Largo Fire Department was the first to respond to the scene. Leonardo Moreno, a volunteer firefighter, tried to enter the hole with his air tank but failed. So, he descended without his air tank and lost consciousness within seconds of entering the drainage hole. Eventually, another firefighter was able to enter the hole with an air tank and pull Moreno out. Unfortunately, the other three construction workers weren’t so lucky. All of them died from hydrogen sulfide poisoning, and Moreno was in critical condition.

Unfortunate events like this are completely avoidable. Comment below how this could have been avoided/prevented by using TapRooT® proactively.

To learn more about this tragic incident click here.

Monday Accident & Lessons Learned: Runaway trailer investigation provides context for action sequence

February 26th, 2018 by

The Rail Accident Investigation Branch (RAIB) investigated and released its report on a runaway trailer that occurred May 28, 2017, in England’s Hope, Derbyshire. The incident occurred when a trailer propelled by a small rail tractor became detached and traveled approximately one mile before coming to a stop. RAIB found that a linchpin had been erroneously inserted.

Chief Inspector of Rail Accidents, Simon French, remarked, “The whole episode, as our report shows, was a saga arising from lack of training, care, and caution.” Peruse the report delineating the circumstances and recommendations here. Read the RAIB report here. Enroll in a TapRooT® course to gain the training necessary to investigate and, further, to prevent incidents.

‘Equipment Failure’ is the cause?

February 22nd, 2018 by
Fire, equipment. failure

Drone view of tank farm fire Photo: West Fargo Fire Department








On Sunday, there was a diesel fuel oil fire at a tank farm in West Fargo, ND. About 1200 barrels of diesel leaked from the tank.  The fire appears to have burned for about 9 hours or so.  They had help from fire dapartments from the local airport and local railway company, and drone support from the National Guard.  There were evacuations of nearby residents.  Soil remediation is in progress, and operations at the facility have resumed.  Read more about the story here.

The fire chief said it looks like there was a failure of the piping and pumping system for the tank. He said that the owners of the tank are investigating. However, one item caught my attention. He said, “In the world of petroleum fires, it wasn’t very big at all. It might not get a full investigation.”

This is a troublesome statement.  Since it wasn’t a big, major fire, and no one was seriously hurt, it doesn’t warrent an investigation.  However, just think of all the terrific lessons learned that could be discovered and learned from.  How major a fire must it be in order to get a “full investigation?”

I often see people minimize issues that were just “equipment failures.”  There isn’t anyone to blame, no bad people to fire, it was just bad equipment.  We’ll just chalk this one up to “equipment failure” and move on.  In this case, that mindset can cause people to ignore the entire accident, and that determining it was equipment failure is as deep as we need to go.

Don’t get caught in this trap.  While I’m sure the tank owner is going to go deeper, I encourage the response teams to do their own root cause analyses to determine if their response was adequate, if notifications correct, if they had reliable lines of communications with external aganecies, etc.  It’s a great opportunity to improve, even if it was only “equipment failure,” and even if you are “only” the response team.

Monday Accident & Lesson Learned: Quick action by mother prevents toddler from falling through hole in moving train

February 19th, 2018 by

A child was rescued from death when his mom grabbed him before he fell through a hole in a moving train.  In a 39-page report published by the Rail Accident Investigation Board, it was revealed that “The child entered the toilet, and as the door opened and the child stepped through it, he fell forward because the floor was missing in the compartment he had entered.” Read the report here.

Top 3 Reasons Corrective Actions Fail & What to Do About It

February 15th, 2018 by

Ken Reed and Benna Dortch discuss the three top reasons corrective actions fail and how to overcome them. Don’t miss this informative video! It is a 15 minute investment of time that will change the way you think about implementing fixes and improve performance at your facility.

Support your Investigation Results with Solid Evidence Collection

February 13th, 2018 by

We have a couple of seats left in the “TapRooT® Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills” 2-day Pre-Summit course, February 26-27 in Knoxville, Tennessee. My co-instructor, Reb Brickey and I are excited to share methods of collection that will help you stop assumptions in their tracks!

Evidence collection techniques help investigators focus on the facts of an investigation. We will talk about pre-planning, different types of evidence to keep in mind as well as spend a good part of the second day learning about and practicing interviewing techniques. The course begins with an interesting case study and attendees break into investigation teams and work toward solving the evidence collection puzzle for the accident presented.

Class size is limited to ensure an ideal learning environment, so register now for the 2-day course only or for the 2-day course plus the 3-day Global TapRooT® Summit.


Stop Assumptions in Their Tracks!

February 13th, 2018 by

Assumptions can cause investigators to reach unproven conclusions.

But investigators often make assumptions without even knowing that they were assuming.

So how do you stop assumptions in their tracks?

When you are drawing your SnapCharT®, you need to ask yourself …

How do I know that?

If you have two ways to verify an Event or a Condition, you probably have a FACT.

But if you have no ways to prove something … you have an assumption.

What if you only have one source of information? You have to evaluate the quality of the source.

What if one eye witness told you the information? Probably you should still consider it an assumption. Can you find physical evidence that provides a second source?

What if you just have one piece of physical evidence? You need to ask how certain you are that this piece of physical evidence can only have one meaning or one cause.

Dashed Boxes

Everything that can’t be proven to be a fact should be in a dashed box or dashed oval on your SnapCharT®. And on the boxes or ovals that you are certain about? List your evidence that proves they are facts.

Now you have stopped assumptions in their tracks!

Monday Accident & Lessons Learned: The Lac-Mégantic rail disaster

February 12th, 2018 by

The Lac-Mégantic rail disaster occurred when an unattended 74-car freight train carrying Bakken Formation crude oil rolled down a 1.2% grade from Nantes and derailed, resulting in the fire and explosion of multiple tank cars. Forty-two people were confirmed dead, with five more missing and presumed dead. More than 30 buildings were destroyed. The death toll of 47 makes it the fourth-deadliest rail accident in Canadian history.


Click image to view or download .pdf


Why You Should Use the TapRooT® Process for Smaller Investigations

February 7th, 2018 by

“If the hammer is your only tool, all of your problems will start looking like nails.”

Per Ohstrom shares how TapRooT® is used to investigate smaller incidents by demonstrating the methodology. Are you using the 5-Whys to investigate these types of incidents? The 5-Whys won’t take you beyond your own knowledge. Find out how TapRooT® will!

How to Make Incident Investigations Easier

January 31st, 2018 by

Ken Reed talks about the differences between an investigation for a low-to-moderate incident and a major incident. Find out how TapRooT® makes both types of investigation easier to manage.

Want to learn how to investigate a major/minor incident with all of the advanced tools? Sign up for an upcoming 5-day training!

Want to start with just the essential skills for performing a root cause analysis on a minor or major investigation? It’s a great place to start with a minor investment of time. Sign up for an upcoming 2-day training!

Root Cause Analysis Tip: Do you perform an incident investigation like you watch the news?

January 31st, 2018 by

If you are like me, you flip channels to see how each news station or news website reports the same issue of interest. Heck, I even look at how different countries discuss the same issue of interest. Take the “Deep Water Horizon Spill of 2010” or was it the “BP Oil Spill of 2010” or was it the “Gulf of Mexico Oil Spill of 2010”? It depends on where you were or what you watched when it was reported. At the end of the day we all often develop Bias Criteria of Trust… often without any true ability to determine which perspective is closer to the truth.

Now there are fancier terms of bias from confirmation bias to hindsight bias, but let’s take a look at some of our news source Bias Criteria of Trust.

So here is the question to stop and ask….. do you do the same thing when you start an investigation, perform root cause analysis or troubleshoot equipment? It is very easy to say YES! We tend to trust interviews and reports using the same criteria above before we actually have the evidence. We also tend to not trust interviews and reports purely because of who and where they came from, without evidence as well!

Knowing this…..

Stop the urge to not trust or to overly trust. Go Out And Look (GOAL) and collect the evidence.

Got your interest? Want to learn more? Feel free to contact me or any of our TapRooT® Instructors at or call 865.539.2139.

Where Do You Get Ideas To Improve Root Cause Analysis?

4 Signs You Need to Improve Your Investigations

4 Signs You Need to Improve Your Investigations

January 29th, 2018 by

If you want to improve your root cause analysis beyond simple techniques that yield incomplete results that don’t stop problems, you are probably ready for step one … implementing the TapRooT® Root Cause Analysis System.

But many find that after they implement the TapRooT® System, they still have room to improve their investigations. Here are four signs that you’re ready for step two:

  1. Investigator Bad Habits – Before your investigators were trained to use TapRooT®, they probably had some other method they used to find “the root cause.” The bad habits they learned probably aren’t completely corrected in a single 2-Day or 5-Day TapRooT® Root Cause Analysis Course. They may have previously been trained that there was only one root cause. They might not know how to interview or collect information (facts). They may need practice drawing complete SnapCharT®s or identifying all the Causal Factors. Therefore, they may need more training or some coaching to complete the development of their skills.
  2. Insufficient Time & Resources – Even if you are a great investigator, you need time to collect evidence and complete your investigation. If you have too little time and if you don’t have adequate resources, the TapRooT® Training alone can’t make your investigations excellent.
  3. Inadequate Investigation Review – Investigators need feedback to improve their skills. Where do they get expert feedback? It could come from management if they are experts in root cause analysis. If management doesn’t understand root cause analysis, the feedback they get may not improve future results. Therefore, you should probably implement a “peer review” before management review occurs. The “peer review” will be done by one or more root cause analysis experts to identify areas for improvement BEFORE the investigation is presented to management. The best peer reviews are conducted while the investigation is being performed. Think of this as just-in-time coaching.
  4. Insufficient Practice – Even with great training to start with, people become “rusty” if they don’t practice their skills. Of course, you don’t want to have more serious incidents to get more experience for your investigators. What can you do? Three things … a) Use the TapRooT® System to investigate less serious but potentially serious incident. The new book, Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents, can show you how to do this without wasting time and effort. b) Use the TapRooT® System to prepare for, perform, and analyze the results of audits. Learn how to do this in the upcoming pre-Summit course, TapRooT® for Audits. Or get the book, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement. c) Have a refresher course for your investigators (contact us for info by CLICKING HERE) or have them attend a pre-Summit Course and the Global TapRooT® Summit to refresh their skills.

Are you ready for step two? Would you like to learn more about improving your implementation of TapRooT® and changing the culture of your companies investigations and root cause analysis? Then get registered for the 2018 Global TapRooT® Summit.


FIRST, Mark Paradies, President of System Improvements and TapRooT® author will be giving a keynote address titled: How Good is Your TapRooT® Implementation. Learn how to apply best practices from around the world to improve your use of TapRooT® Root Cause Analysis.


SECOND, Jack Frost, Vice President HSE of Matrix Service Company, will be giving a Best Practice Track talk titled: Improving Safety Culture Through Measuring and Grading Investigations. In this session he will discuss using an evaluation matrix to grade your investigations and coach your investigators to better root cause analysis.

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You can download the matrix that Jack uses here:

Don’t be satisfied. Continually improve your root cause analysis!

Monday Accident & Lessons Learned: How Long Should a Root Cause Analysis Take?

January 29th, 2018 by

Screen Shot 2018 01 27 at 2 48 07 PM

On January 25th, The Atlanta Journal-Constitution reported that Georgia Power had not identified the cause of the December 17th electrical fire that shut down power to large portions of Atlanta’s Hartsfield-Jackson Airport. The article reports that the service disruption caused massive passenger disruptions and will cost $230,000 to repair. Delta says that the disruption from the fire and an early December snow storm will cost the airlines $60 million dollars.

Obviously this incident is worth preventing and needs an effective root cause analysis. It has been over a month since the fire. The questions is … how long should a root cause analysis take? A month, three months, a year, three years?

Of course, the answer varies depending on the type of the incident but what do you think is reasonable?

Leave your comments by clicking on the Comment link below.

CSB to Investigate Fatal Well Explosion in Oklahoma

January 27th, 2018 by

I don’t know when the CSB became the drilling investigator but here is their press release announcing the investigation…


CSB Will Investigate Fatal Well Explosion in Oklahoma

Washington D.C. January 25, 2018 – The U.S. Chemical Safety Board announced today that it will be moving forward with a full investigation into the fatal gas well explosion near Quinton, Oklahoma. The explosion fatally injured five workers.

Upon notification of the incident, the CSB deployed two investigators to gather additional facts  to assist the Board in making  a decision regarding the scope of the investigation. Investigators arrived on site Wednesday morning and met with the lease holder for the well and the drilling operator.  CSB investigators will continue to meet with well service providers and the well site consultant company that had employees on site at the time of the incident. Evidence preservation and collection is the initial focus of the investigation.

The CSB is an independent, non-regulatory federal agency whose mission is to drive chemical safety change through independent investigations to protect people and the environment. The agency’s board members are appointed by the President and confirmed by the Senate.

CSB investigations examine all aspects of chemical incidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems. For more information, contact

Is this a good idea? … Navy to have “Article 32” hearings for COs involved in collisions at sea.

January 17th, 2018 by


Didn’t I just read (see this LINK) a Navy investigation that implied there were Management System causes of the two collisions in the Pacific? Didn’t the report suggest that the Navy needed to change it’s culture?

An article in USNI News says that both Commander Alfredo J. Sanchez and Commander Bryce Benson will face Article 32 hearings (the prelude to a court martial) over their role in the ships’ collisions in the Pacific.


Will punishment make the Navy better? Will it make it easier for ship’s commanding officers to admit mistakes? And what about the crew members who are facing disciplinary hearings? Will that make the culture of the Navy change from a reactive-punitive culture to a culture where mistakes are shared and learned from BEFORE major accidents happen?

What do you think…

Here is the press release from the Navy’s Consolidated Disposal Authority (Director of Naval Reactors Adm. James F. Caldwell):

On 30 October 2017, Admiral William Moran, Vice Chief of Naval Operations, designated Admiral Frank Caldwell as the Consolidated Disposition Authority to review the accountability actions taken to date in relation to USS Fitzgerald (DDG 62) and USS John S. McCain (DDG 56) collisions and to take additional administrative or disciplinary actions as appropriate.

After careful deliberation, today Admiral Frank Caldwell announced that Uniform Code of Military Justice (UCMJ) charges are being preferred against individual service members in relation to the collisions.

USS Fitzgerald: Courts-martial proceedings/Article 32 hearings are being convened to review evidence supporting possible criminal charges against Fitzgerald members. The members’ ranks include one Commander (the Commanding Officer), two Lieutenants, and one Lieutenant Junior Grade. The charges include dereliction of duty, hazarding a vessel, and negligent homicide.

USS John S. McCain: Additionally, for John S. McCain, one court- martial proceeding/Article 32 hearing is being convened to review evidence supporting possible criminal charges against one Commander (the Commanding Officer). The charges include dereliction of duty, hazarding a vessel, and negligent homicide. Also, one charge of dereliction of duty was preferred and is pending referral to a forum for a Chief Petty Officer.

The announcement of an Article 32 hearing and referral to a court-martial is not intended to and does not reflect a determination of guilt or innocence related to any offenses. All individuals alleged to have committed misconduct are entitled to a presumption of innocence.

Additional administrative actions are being conducted for members of both crews including non-judicial punishment for four Fitzgerald and four John S. McCain crewmembers.

Information regarding further actions, if warranted, will be discussed at the appropriate time.

Equipment Troubleshooting in the Future

January 5th, 2018 by

Equipment Troubleshooting in the Future
By Natalie Tabler and Ken Reed

If you haven’t read the article by Udo Gollub on the Fourth Industrial Revolution, take some time to open this link. This article can actually be found at many links on the internet, so attribution is not 100% certain, but Mr. Gollub appears to be the probable author.

The article is interesting. It discusses a viewpoint that, in the current stage of our technological development, disruptive technologies are able to very quickly change our everyday technological expectations into “yesterday’s news.” What we consider normal today can be quickly overtaken and supplanted by new technology and paradigms. While this is an interesting viewpoint, one of the things I don’t see discussed is one of the most common problems with automating our society: equipment failure. If our world will largely depend on software controlling machinery, then we need to take a long hard look at avoiding failure not only in the manufacturing process, but also in the software development process.

The industrial revolution that brought us from an agricultural society to an industrial one also brought numerous problems along with the benefits. Changing how the work is done (computerization vs. manual labor) does not change human nature. The rush to be first to come out with a product (whether it be new software or a physical product) will remain inherent in the business equation, and with it the danger of not adequately testing, or overly optimistic expectations of benefit and refusal to admit weaknesses.

If we are talking about gaming software – no big deal. So, getting to the next level of The Legend of Zelda – Breath of the Wind had some glitches; that can be changed with the next update. But what if we are talking about self-driving cars or medical diagnostic equipment? With no human interaction with the machine (or software running it) the results could be catastrophic. And what about companies tempted to cut some corners in order to bolster profits (remember the Ford Pinto, Takata airbags, and the thousands of other recalls that cost lives)? Even ethical companies can produce defective products because of lack of knowledge or foresight. Imagine if there were little or no controls in production or end use.

Additionally, as the systems get more complex, the probability of unexpected or unrecognized error modes will also increase at a rapid rate. The Air France Flight 447 crash is a great example of this.

So what can be done to minimize these errors that will undoubtedly occur? There are really 2 options:

1. Preventative, proactive analysis safety and equipment failure prevention training will be essential as these new technologies evolve. This must also be extended to software development, since it will be the driving force in new technologies production. If you wonder how much failure prevention training is being used in this industry, just count the number of updates your computer and phone software sends out each year. And yes, failure prevention should include vigilance on security breaches. A firm understanding of human error, especially in the software and equipment design phase, is essential to understanding why an error might be introduced, and what systems we will need in place to catch or mitigate the consequences of these errors.  This obviously requires effective root cause analysis early in the process.

2. The second option is to fully analyze the results of any errors after they crop up. Since failures are harder to detect as stated in #1, it becomes even more critical that, when an error does cause a problem, we dig deep enough to fix the root cause of the failure. It will not be enough to say, “Yes, that line of code caused this issue. Corrective action: Update the line of code.” We must look more deeply into how we allowed the errant line of code to exist, and then do a rigorous generic cause analysis to see of we have this same issue elsewhere in our system.

With the potential for rapidly-evolving hardware and software systems causing errors, it will be incumbent on companies to have rigorous, effective failure analysis to prevent or minimize the effects of these errors.

Want to learn more about equipment troubleshooting? Attend our Special 2-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis training February 26 and 27, 2018 in Knoxville, Tennessee and plan to stay for the 2018 Global TapRooT® Summit, February 28 to March 2, 2018.

The Georgia State Public Services Commission Demands Root Cause Analysis of Atlanta Airport Blackout

December 21st, 2017 by


Read about the story in The Atlanta Journal-Constitution:

It’s hard to believe there wasn’t a redundant transmission line and transformers to such a vital resource.

Hack of safety system causes plant shutdown …

December 18th, 2017 by

Jim Whiting (TapRooT® Instructor) sent me this link to a plant shutdown caused by a hack of a safety system computer code.

There isn’t a lot of specifics in the article but it does make one wonder about the applicable corrective actions and how they should be applied across the whole industry.

Secretary of the Navy Strategic Readiness Review – Management System Problems Broke the US Navy

December 14th, 2017 by

Yes, “Management System Problems Broke the US Navy” is my headline.


The report to the Secretary of the Navy is much worse than I thought. The report outlines how budget restrictions and congressional leadership made the Navy conform to the structures of the Army and the Air Force and de-emphasized the role of providing seapower. That’s how the US Navy was broken. And it will be difficult to fix. (“All the King’s horses and all the King’s men couldn’t put Humpty Dumpty together again!” was a lesson learned in 1648 during the English civil war.)


Many of the problems are Management System problems as outlined in a Navy Times article about the Strategic Review report to the Secretary of the Navy. The good news is … the authors of the Strategic Review get the Management System root causes pretty much right! The bad news is that it is less clear that the Navy has the ability to fix the issues because they are a result of Congressional action (funding, ship procurement, the Defense Officer Personnel Management Act, the Goldwater-Nichols Act of 1986, and National Defense Authorization Act provisions) and the Navy’s response to congressional cutbacks (Optimum Manning, the SWOS-in-a-box, modifications to the surface warfare officer sea-shore rotations and assignments, and the 2001 Revolution in Training for enlisted personnel).

The review says that the Navy must cut back their commitments to operational requirements in “peacetime.” But that is unlikely in the near wartime footing that they Navy faces in their forward deployments.

One of the recommendations made by the Strategic Review is for the Type Commanders to implement the “Rickover Letters” that are part of the Nuclear Navy Commanding Officer reporting structure. This will only work if the Type Commanders maintain strict requirements that Admiral Rickover established in the Nuclear Navy. This has not been the culture in the conventional surface Navy – EVER. Thus this would be a dramatic cultural shift.

Navy brass in the 1980’s and 1990’s wished that sailors at sea could do more with less and that “technology” would make that possible. Unfortunately the cuts were made (Optimal Manning and Continuous Maintenance Plan) without proof of concept testing. Now, over two decades later, the chickens have come home to roost.

The USA is an island nation. We can’t exist in our modern economy without sea trade. Thus, the USA must be the premier sea power. This requirement is independent of the “War on Terror,” the “War on Drugs,” or other missions to support land forces. Somehow past Presidents and Congressional leaders have not funded the seapower mission. Thus, we find ourselves in a bind that will be hard to fix.

The people in senior Navy leadership positions have grown up in a broken system. We must now ask them to fix (restore) the system when they have never seen it work properly. The CNO in a Navy Nuke from the submarine fleet that has faced budget reductions but has not faced the same personnel and training issues. He grew up in a different culture.

By making the US Navy the “same” as the Air Force and the Army, the unique requirements of the Navy were overlooked and the Navy was broken. Can it be fixed? The recommendations of the Strategic Review could start the repair process. But it is only a start. Many uniquely “Navy” cultural and readiness issues are not addressed in the report. Plus, this report probably will not get the attention it deserves until a failure of our war-fighting ability at sea produces a major foreign policy fiasco or, even worse, economic collapse at home because our island nation is cut off from overseas supplies.

One last comment.

The Strategic Review calls for the establishment of a “learning culture.” The authors of the Strategic Review call for proactive learning instead of the current culture of punishment based reactive learning. They frequently mention the “normalization-of-deviation” as if it a relatively recent US Navy cultural problem rather than being the state of the conventional surface navy for decades (or centuries?). They should read the article about Admiral Rickover and the normalization-of-excellence to better understand the changes that are needed. Also, establishing a proactive, learning culture isn’t possible until the US Navy understands advanced root cause analysis (which current investigations and corrective actions prove that the Navy does not understand).

The recommendations of section 6.3 of the Strategic Review are putting the “cart in front of the horse.” The FIRST step in correcting the Navy’s culture is for all naval officers (senior commanders through junior officers) to understand advanced root cause analysis. Without this understanding, learning – either proactive or reactive – is impossible. We have worked with industry leaders and we know of what we speak.

I certainly hope the US Navy makes significant progress in correcting the glaring shortcomings outlined in the Strategic Review. The lives of sailors at sea depend on it. But even worse, a failure to fix the root causes of the Management System problems and the poor understanding of advanced root cause analysis will certainly lead to failures of our seapower and serious foreign policy issues that may cause tremendous economic troubles for the US. I’m old and may not see the day when we discover that under-investment in seapower was a gigantic mistake. But if this problem isn’t fixed rapidly and effectively, certainly my children and grandchildren will face an uncertain, dark future.

I would be happy to discuss the improvements in root cause analysis that are needed with any Navy leader concerned that a more effective approach is needed.

My 20+ Year Relationship with 5-Why’s

December 11th, 2017 by

I first heard of 5-Why’s over 20 years ago when I got my first job in Quality. I had no experience of any kind, I got the job because I worked with the Quality Manager’s wife in another department and she told him I was a good guy. True story…but that’s how things worked back then!

When I was first exposed to the 5-Why concept, it did not really make any sense to me; I could not understand how it actually could work, as it seemed like the only thing it revealed was the obvious. So, if it is obvious, why do I need it? That is a pretty good question from someone who did not know much at the time.

I dived into Quality and got all the certifications, went to all the classes and conferences, and helped my company build an industry leading program from the ground up. A recurring concept in the study and materials I was exposed to was 5-Why. I learned the “correct” way to do it. Now I understood it, but I still never thought it was a good way to find root causes.

I transferred to another division of the company to run their safety program. I did not know how to run a safety program – I did know all the rules, as I had been auditing them for years, but I really did not know how to run the program. But I did know quality, and those concepts helped me instill an improvement mindset in the leaders which we successfully applied to safety.

The first thing I did when I took the job was to look at the safety policies and procedures, and there it was; when you have an incident, “ask Why 5 times” to get your root cause! That was the extent of the guidance. So whatever random thought was your fifth Why would be the root cause on the report! The people using it had absolutely no idea how the concept worked or how to do it. And my review of old reports validated this. Since then I have realized this is a common theme with 5-Why’s; there is a very wide variation in the way it is used. I don’t believe it works particularly well even when used correctly, but it usually isn’t in my experience.

Since retiring from my career and coming to work with TapRooT®, I’ve had literally hundreds of conversations with colleagues, clients, and potential clients about 5-Why’s. I used to be somewhat soft when criticizing 5-Why’s and just try to help people understand why TapRooT® gets better results. Recently, I’ve started to take a more militant approach. Why? Because most of the people I talk to already know that 5-Why’s does not work well, but they still use it anyway (easier/cheaper/quicker)!

So it is time to take the gloves off; let’s not dance around this any longer. To quote Mark Paradies:
“5-Why’s is Root Cause Malpractice!”

To those that are still dug in and take offense, I do apologize! I can only share my experience.

For more information, here are some previous blog articles:

What’s Wrong With Cause-and-Effect, 5-Why’s, & Fault Trees

Comparing TapRooT® to Other Root Cause Tools

What’s Fundamentally Wrong with 5-Whys?

Fake News or Real?

December 6th, 2017 by


That’s the headline. Here is the link:

Could it really be true? I guess the funeral home industry needs TapRooT®!

(Editor’s update: After this post was published, Snopes reported this as fake news and the news story was removed. Thank goodness!)

Not Near-Misses … They Are Precursors

December 5th, 2017 by

I had an epiphany today.

Have you ever noticed how management doesn’t take near-miss incidents seriously? They don’t see them as just one step away from a fatality?

I think part of the problem may be the terminology.

Near-miss just doesn’t sound very serious. After all … it was a miss.

But what if we called these incidents PRECURSORS.

A precursor tells you that something IS going to happen unless you change.

If management saw these incidents as an indicator that something was GOING TO HAPPEN, then, maybe, they would take action.

You may have already thought of this and changed the language that you use around incidents … but I haven’t seen the words PRECURSOR INCIDENTS used very often. Now may be the time to start.

One more thing … Precursor Incidents mean that incidents that could not cause an accident ARE NOT precursors. Thus, paper cuts are not precursors of amputations.

Therefore, we can stop wasting our time investigating incidents that will never cause a serious injury.

Just a thought…

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