Category: Performance Improvement

Benchmark Your Root Cause Analysis Efforts

July 30th, 2014 by


I’ve had many people ask me to comment on their use of root cause analysis. How are they doing? How do they compare to others? So I thought I’d make a simple comparison table that people could use to see how they were doing (in my opinion). I’ve chosen to rate the efforts as one of the following categories …

  • Bad
  • Better
  • Even Better
  • Excellent

For each of these categories I’ve tried to answer the following questions about the efforts so that you could see which one most closely parallels your efforts. The questions are:

  • Who?
  • What?
  • When?
  • Where?
  • To What Extent?
  • Under What Conditions?


This is one step above no effort to find root causes.

Who performs the root cause analysis? The supervisor involved.

What do they use to perform the root cause analysis? 5-Why’s or no technique at all.

When do they perform the root cause analysis? In their spare time. (They must do their regular job and do the root cause analysis at the same time.)

Where do they perform the root cause analysis? Mainly in their office – they may do a few simple interviews with employees out in the plant but they don’t have a quite, private room for interviewing.

To what extent do they pursue root causes? Usually as far as they think management will push them to go. If they can find a piece of equipment or a person to blame, that is far enough. The corrective actions can be to fix the equipment or to discipline the person and that is all that is needed.

Under what conditions do they perform the root cause analysis? They are in a hurry because management needs to know who to punish. Or the punishment may come before the root cause analysis is completed. They also know that if they can’t make a good case for someone else being blamed, they may get blamed for not having done a thorough pre-job risk assessment (call it a job safety analysis, pre-job brief, or pre-job planning if those terms fit better at your company). One more thing to worry about is that they certainly can’t point out any management system flaws or they may become a target of management’s wrath.


The problems with a BAD root cause analysis effort is that the solutions implemented seldom cause improvement. You frequently see very similar incidents happen over and over again due to uncorrected root causes.

Also, the root cause analysis tends to add to morale problems. People don’t like to be blamed and punished even if they may think that it was their fault. They especially don’t like it when they feel they are being made a scape goat. 

Finally, because near-misses and small problems aren’t solved effectively, there is a chance that the issues involved can cause a major accident that results in a fatality (or even worse, multiple fatalities). In almost every major accident, there were chances to learn from previous smaller issues. If these issues had been addressed effectively with a thorough root cause analysis and corrective actions, the major accident would have never occurred.


Better is better than bad, but still has problems.

Who performs the root cause analysis? The supervisor involved.

What do they use to perform the root cause analysis? TapRooT®.

When do they perform the root cause analysis? In their spare time. (Similar to BAD.)

Where do they perform the root cause analysis? Mainly in their office. (Similar to BAD.)

To what extent do they pursue root causes? They use the Root Cause Tree® and find at least one root cause for at least a few of the Causal Factors.

Under what conditions do they perform the root cause analysis? They are trained in only the minimum knowledge to use TapRooT®. Sometimes they don’t even get the full 2-Day TapRooT® Course but instead are given a “short course” which should be “good enough” for supervisors. (Supervisors don’t have time to attend two days of root cause analysis training.) They often treat the Root Cause Tree® as a pick list and don’t use (or perhaps don’t have a copy of) the Root Cause Tree® Dictionary to use to guide their root cause analysis. Also, they may not understand the importance of having a complete SnapCharT® to understand what happened before they start trying to find out why it happened (using the Root Cause Tree®). And they probably don’t use the Corrective Action Helper® to develop effective corrective actions. Instead, rely on the well understood three standard corrective actions: Discipline, Training, and Procedures.


The problems with a BETTER root cause analysis effort is that people claim to be doing a thorough TapRooT® root cause analysis and they aren’t. Thus they miss root causes that they should have identified and they implement ineffective fixes (or at best, the weakest corrective action – training). The results may be better than not using TapRooT® (they may have learned something in their training) but they aren’t getting the full benefit of the tools they are using. Their misuse of the system gives TapRooT® a bad name at their site. 

Also, because near-misses and small problems aren’t solved effectively, there is a chance that the issues involved can cause a major accident (just like the BAD example above).


Even better is the minimum that you should be shooting for. Don’t settle for less.

Who performs the root cause analysis? A well trained investigator. This investigator should have some independence from the actual incident.

What do they use to perform the root cause analysis? TapRooT®.

When do they perform the root cause analysis? They either have time set aside in their normal schedules to perform investigations or they are relived of their regular duties to perform the investigation. They also have a reasonable time frame to complete the investigation.

Where do they perform the root cause analysis? They probably use a regular conference room to conduct interviews away from the “factory floor”. 

To what extent do they pursue root causes? They use the tools in TapRooT® to their fullest. This includes developing a thorough SnapCharT®, Safeguards Analysis to identify or confirm Causal Factors, the Root Cause Tree® and the Root Cause Tree® Dictionary to find root causes. And Safeguards Analysis and the Corrective Action Helper® to develop effective fixes.

Under what conditions do they perform the root cause analysis? They have support from management, who are also trained in what is required to find root causes using TapRooT®. They have experienced experts to consult with for difficult root cause analysis process questions. If it is a major investigation, they have the help of appropriate investigation team members and the root cause analysis effort is performed with a real time peer review process from another experienced TapRooT® facilitator. 


There aren’t too many problems here. There is room for improvement but the root cause analysis process and fixes are generally very effective. Smaller problems tend to be fixed effectively and help prevent major accidents from occurring.

The one issue tends to be that as performance improves, investigators get less and less experience using the TapRooT® techniques. New investigators don’t get the practice and feedback they need to develop their skills.




Read Chapter 6, section 6.3, of the TapRooT® Book for a complete description of what an excellent implementation of TapRooT® looks like. This kind of TapRooT® implementation should be your long term root cause analysis effort goal. The following is a brief description of what Chapter 6 covers.

Who performs the root cause analysis? For major investigations, a well trained facilitator with a trained team. For more minor investigations, a trained investigator. The site investigation policy should clearly identify the investigative effort needed based on the actual and potential consequences of the particular incident.

What do they use to perform the root cause analysis? TapRooT®.

When do they perform the root cause analysis? Per the company’s pre-planning, the investigator and team either have time set aside in their normal schedules to perform investigations or they are relived of their regular duties to perform the investigation. They also have a reasonable time frame to complete the investigation.

Where do they perform the root cause analysis? For a major investigation an appropriate room is set aside for the team and they use a regular conference room to conduct interviews away from the “factory floor”. 

To what extent do they pursue root causes? They use the tools in TapRooT® to their fullest. 

Under what conditions do they perform the root cause analysis? The management sponsor has pre-approved a performance improvement policy that covers the investigation process. managers, facilitators, and all employees involved are trained per the policy standards. A no blame or “just” culture has been established and the purpose of the investigation is understood to be performance improvement. 


You can’t be excellent without a senior management sponsor and management support. And being excellent is a never ending improvement process.

Also, as performance improves, investigator get less experience with reactive investigations. Therefore, proactive use of TapRooT® must be an integral part of any EXCELLENT TapRooT® root cause analysis effort. Proactive use of TapRooT® is covered in Chapter 4 of the TapRooT® Book and an example of proactive use of TapRooT®, the after action review, is provided HERE


How did your root cause analysis efforts compare? What do you need to improve? Even if you are EXCELLENT, you need to continuously improve your efforts. For even more improvement ideas and benchmarking, consider attending the 2015 Global TapRooT® Summit in Las Vegas on June 1-5. For more information, see:

Corrective Action for Natural Disaster Category on the Root Cause Tree®

July 24th, 2014 by

Are you prepared for a tornado at your facility?

Watch what nuclear power plants (Watts Bar NPP – part of TVA) are doing …

Monday Accident & Lessons Learned: Human Error Leads to Near-Miss at Railroad Crossing in UK – Can We Learn Lessons From This?

June 23rd, 2014 by

Here’s the summary from the UK RAIB report:


At around 05:56 hrs on Thursday 6 June 2013, train 2M43, the 04:34 hrs passenger service from Swansea to Shrewsbury, was driven over Llandovery level crossing in the town of Llandovery in Carmarthenshire, Wales, while the crossing was open to road traffic. As the train approached the level crossing, a van drove over immediately in front of it. A witness working in a garage next to the level crossing saw what had happened and reported the incident to the police.

The level crossing is operated by the train’s conductor using a control panel located on the station platform. The level crossing was still open to road traffic because the conductor of train 2M43 had not operated the level crossing controls. The conductor did not operate the level crossing because he may have had a lapse in concentration, and may have become distracted by other events at Llandovery station.

The train driver did not notice that the level crossing had not been operated because he may have been distracted by events before and during the train’s stop at Llandovery, and the positioning of equipment provided at Llandovery station relating to the operation of trains over the level crossing was sub-optimal.

The RAIB identified that an opportunity to integrate the operation of Llandovery level crossing into the signalling arrangements (which would have prevented this incident) was missed when signalling works were planned and commissioned at Llandovery between 2007 and 2010. The RAIB also identified that there was no formalised method of work for train operations at Llandovery.

The RAIB has made six recommendations. Four are to the train operator, Arriva Trains Wales, and focus on improving the position of platform equipment, identifying locations where traincrew carry out operational tasks and issuing methods of work for those locations, improvements to its operational risk management arrangements and improving the guidance given to its duty control managers on handling serious operational irregularities such as the one that occurred at Llandovery.

Two recommendations are made to Network Rail. These relate to improvements to its processes for signalling projects, to require the wider consideration of reasonable opportunities to make improvements when defining the scope of these projects, and consideration of the practicability of providing a clear indication to train crew when Llandovery level crossing, and other crossings of a similar design, are still open to road traffic.

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The full report has very interesting information about the possibility of fatigue playing a part in this near miss. See the whole report HERE.

This report is an excellent example of how much can be learned from a near-miss. People are more whilling to talk when a potential near-fatal accident happens than when a fatality happens. And all of this started because a bystander reported the near-miss (not the train crew or the driver).

How can you improve the reporting and investigation of potentially fatal near-miss accidents? Could your improvements in this area help stop fatalities?



Tide and Time Wait for No Man

June 18th, 2014 by

Tide and Time Wait for No Man
(reprinted from the May 2014 Root Cause Network™ Newsletter by permission)


Some TapRooT® Users lament: 

“I don’t get enough practice using TapRooT® to be good at finding root causes.”

Why do they say that? Because they only use TapRooT® to investigate major accidents. For most TapRooT® users, major accidents a re few and far between.

Not having major accidents is a good thing, so this complaint isn’t all bad. But why aren’t they getting practice using TapRooT® proactively to find root causes and improve performance? I think the answer to this question has to do with the effective use of TIME. 


There’s never enough time to do it right, but there’s always enough time to do it over. - Jack Bergman

The first thing that I notice is that most people are reactive. They aren’t planning ahead. Rather, they respond as things go wrong. As W. Edwards Deming said: 

Stamping out fires is fun, but it only puts things back the way they were. 


To become excellent is to look ahead and avoid firefighting and being reactive.  

But many complain that they just don’t have the time to be proactive and get ahead of the problems they face. They should remember: 

 The great dividing line between success and failure
can be expressed in five words: “I did not have time.” – Franklin Field

Lack of time is always an excuse. Here are two quotes to remember when someone complains about having too little time: 

If you have time to whine and complain about something
then you have the time to do something about it.
- Anthony J. D’Angelo

 and …

One always has enough time if one will apply it well. - Johann Wolfgang von Goethe


The first step in creating time for proactive analysis is to avoid wasting time on ineffective reactive efforts. 

Start by being good when reactive improvement is called for. Get the training you need to apply TapRooT® effectively (we suggest the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course) and continue to learn by attending the TapRooT® Summit.

Next, make sure that your reactive investigations are as efficient as possible. Read Chapter 3 of the 2008 version of the TapRooT® Book to make sure that you are applying all the ways it recommends to save time during investigations. Also, review Appendix C, A Guide to Improving the Use of TapRooT®, in the TapRooT® Book to find even more ways to save time and effort.


Next, make sure that you aren’t wasting time investigating problems that aren’t important. Focus your reactive root cause analysis efforts on incidents that are truly significant or that could have caused a significant accident.

Finally, if you are a manager, be well trained in root cause analysis so that you ask good questions and know what to look for when you are reviewing investigators’ recommendations. That will keep you from wasting your investigators’ time.  


Start small and start now using TapRooT® proactively to find and fix the root causes of problems before they happen.  

Don’t wait. The time will never be just right. - Napoleon Hill


Learn how to use TapRooT® proactively by reading Chapter 4 of the TapRooT® Book. Also, read this LINK  to get ideas about using TapRooT® root cause analysis proactively in after action reviews. What if you still can’t see how to find the time for proactive improvement? 

In truth, people can generally make time for what they choose to do;
it is not really the time but the will that is lacking
. – Sir John Lubbock


To develop more “will” to be proactive, picture success. Picture… 

  • Never having to investigate a major accident – EVER. 
  • No fatalities. 
  • Crisis management eliminated. 
  • Reliable equipment that doesn’t fail when you need it the most. 
  • No major cost overruns and no major schedule slippages.
  • Happy clients that aren’t complaining about quality issues.

The only way to achieve this goal is by systematically, proactively improving using root cause analysis. Reactive root cause analysis will never get you to this picture of success. 

Success is simple. Do what’s right,  the right way, at the right time. - Arnold H. Glasgow

If you still need help after you’ve attended TapRooT® Training, read the TapRooT® Book, and tried becoming proactive, give us a call (865-539-2139) or drop us a note (click here) and ask us for more ideas to address your specific problems. We’ll be glad to help you apply TapRooT® root cause analysis proactively to achieve performance excellence.

Finally, remember… 

Time is not measured by the passing of years, 
but by what one does,
what one feels, and
what one achieves.
- Jawaharlal Nehru



Monday Accident & Lessons Learned: You Don’t Have to be in a High Risk Industry to be Killed on the Job

June 16th, 2014 by



This fatal accident should remind all of us that you don’t have to be in a high risk occupation to be killed on the job. A forklift in the warehouse is all that is needed to provide the energy needed to start a fatal accident. See the press report here of a recent forklift fatality that is being investigated by OSHA:

Proactive use of root cause analysis is needed in all sorts of industries to improve safety and prevent fatal accidents. Are you doing all you can to keep your employees safe?

US BLS Releases Statistics on Workplace Deaths

June 5th, 2014 by


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The US Bureau of Labor Statistics release some interesting information about workplace fatalities in a recent press release.

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It would be interesting to see these statistics graphed on an XmR Chart … as we teach in our Advanced Trending Techniques Course. If you are interested in learning advanced trending techniques, you missed our 2014 course. But we are planning to offer the course again on June 1-2, 2015 prior to the 2015 TapRooT® Summit (June 3-5, Las Vegas, NV). I know that’s a long ways ahead to start planning but you probably can’t say that your schedule is already full.

One more note, if you have a bunch of folks at your company who need to learn advanced trending techniques, we can come to your site to present the course. If you are interested, CLICK HERE to contact us.



Do You Want A World-Class Improvement Program? Root Cause Network™ Newsletter, May 2014, Issue 121

May 25th, 2014 by

Do you want a World-Class Improvement Program? Then read “Tide and Time Wait for No Man” on page 1 of this month’s Root Cause Network™ Newsletter. Download your copy of the newsletter by clicking on this link:



What else is in this month’s Root Cause Network™ Newsletter? Here’s a list…
  • 5 Ways to Improve Your Interviews (Page 2)
  • Best Practice from the 2014 Global TapRooT® Summit: The TapRooT® Expert Help Desk (Page 2)
  • How things naturally go from “Excellence to Complacency” (Page 2)
  • A new idea … “Budget for Your Next Accident” (Page 3)
  • Dilbert Joke (Page 3)
  • An answer to “Is Human Error a Root Cause?” (Page 3)
  • A list of upcoming public TapRooT® Courses – Is one near you? (Page 4)
These articles are quick reads with interesting information. If you are interested in improvement, print the pdf at the link below and get reading:


Mark Approaches 11,000 Direct Connections on LinkedIn

May 18th, 2014 by


Mark Paradies, President, System Improvements, is building a network of people interested in root cause analysis and improving incident and accident investigations. Help him reach a milestone of 11,000 direct connections on LinkedIn. At the writing of this post, he only needs 22 more connections to reach this goal. To see his profile and send him an invitation to join his network, go to:


Monday Motivation: Be Curious!

April 21st, 2014 by



Albert Einstein:

I have no special talents. I am only passionately curious.

Monday Accident & Lessons Learned: Was the Baker Report a Failure?

April 14th, 2014 by

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For those that have followed BP’s accidents (the explosion at Texas City and the blowout and explosion of the Macondo well to name the most prominent), the Baker Report is a famous independent review of the failure of process safety at BP.

I was reading a discussion about process safety and someone brought up the Baker Report as an excellent source for process safety knowledge. That got me thinking, “Was the Baker Report successful?”

The initial Panel Statement at the start of the report includes this quote:

“In the aftermath of the accident, BP followed the recommendation of the U. S. Chemical Safety and Hazard Investigation Board and formed this independent panel to conduct a thorough review of the company’s corporate safety culture, safety management systems, and corporate safety oversight at its U.S. refineries. We issue our findings and make specific and extensive recommendations. If implemented and sustained, these recommendations can significantly improve BP’s process safety performance.”

I believe the Deepwater Horizon/Macondo accident provides evidence that BP as a corporation either didn’t learn the lessons of the report or didn’t implement the fixes across the corporation, or that the report was not successful in highlighting areas to be changed and getting management’s attention.

What do you think?

Was the report successful? Did it cause change and help BP have an improved process safety culture?

Or did the report fail to cause change across the company?

And if it failed, why did it fail?

Let me know your ideas by leaving your comments by clicking on the comments link below.

Monday Motivation: Do You Have the Passion to Keep Going?

April 14th, 2014 by


Steve Jobs:

You have to be burning with an idea, or a problem, or a wrong that you want to right. If you’re not passionate enough from the start, you’ll never stick it out.

Monday Motivation: Harriet Tubman

April 7th, 2014 by



Harriet Tubman:

Every great dream begins with a dreamer. Always remember, you have within you the strength, the patience, and the passion to reach for the stars to change the world.

Thought Leaders to Meet at Summit near Austin … Will You Be There?

March 26th, 2014 by

MarkIrelandWhat is a “thought leader”? I wasn’t sure what that meant when I heard the term recently because I wasn’t up-to-date with the latest lingo.

So, I read a Forbes article about thought leaders, (“What is a Thought Leader,” Russ Alan Prince and Bruce Rogers, March 16, 2012). Here’s how the article defined them:

Thought Leader Definition Part 1:

“A thought leader is an individual or firm that prospects, clients, referral sources, intermediaries and even competitors recognize as one of the foremost authorities in selected areas of specialization, resulting in its being the go-to individual or organization for said expertise.”

Thought Leader Definition Part 2:

“A thought leader is an individual or firm that significantly profits from being recognized as such.”

This made me curious, so I dug a little deeper and discovered five unmistakable qualities of a thought leader:

1. Thought leaders are driven by a higher purpose. The reward they seek is more than money; they find reward in a work that is a service to other human beings in some way.

2. Thought leaders implement positive change by first seeing things differently than the rest of the crowd. Their work helps people become unstuck and move forward.

3. Thought leaders are highly motivated and passionate about their missions. This inspires everyone they come into contact with to make a change for the better.

4. Thought leaders focus on their one big thing for decades. They are energized by expansiveness, but have always been driven toward solving one big problem.

5. Thought leaders are interested in creating positive change in the lives of others because they love people. They become students of human behavior, and are more interested in your story than their own.

That got me thinking. People at the Global TapRooT® Summit are thought leaders!

They are individuals and companies that are recognized as leaders in certain specialized areas or industry leaders AND they benefit from the knowledge they learn and take back and apply from the Summit.

Are you a thought leader? Do you want to be a thought leader? 

Then you should register NOW for the 2014 Global TapRooT® Summit at Horseshoe Bay near Austin, Texas. The pre-Summit courses are on April 7-8. The Summit is next week – April 9-11.

For more information, see:

Root Cause Analysis Tip: Why do supervisors perform BAD root cause analysis?

March 26th, 2014 by


I often hear the complaint. “Our supervisors produce poor quality root cause analysis and incident investigations. Why can’t they do better?” Read on for several potential reasons and solutions…


Probably the most serious problem that prevents supervisors from performing good investigations is the blame game. Everyone has seen it. Management insists that someone must be punished for an error. Why does this cause problems? Because supervisors know that their people or even the supervisor is the most likely discipline target. They learn to blame the equipment to avoid useless discipline. And they know better than to blame management. That would surely result in retribution. Therefore, their investigations are light on facts and blame the equipment.

Obviously, to solve this problem, the whole management approach to human error and performance improvement must change. Good luck!


Supervisors are seldom given the proper training or time to do a good investigation. Training may be a four-hour course in five whys. What a joke! Then, they perform the investigations in their spare time.

What do they need? The same training in advanced root cause analysis that anyone else needs to solve serious problems. A minimum of a 2-Day TapRooT® Course. But a 3-Day TapRooT®/Equifactor® Course would be better for Maintenance Supervisors. Better yet, a 5-Day TapRooT® Course to teach them TapRooT® and additional skills about analyzing human performance and collecting information.

As for time to perform the investigation, it’s best to bring in a relief supervisor to give them time to focus on the investigation.


The last step is to motivate supervisors. They need to be rewarded for producing a good investigation with the unvarnished truth. If you don’t reward good investigations, you shouldn’t expect good investigations.

Learn more about TapRooT® Training at:

Human Performance Tools: What’s Right … What’s Wrong

March 19th, 2014 by



Over the past decade, best practices and techniques have been developed “stop” or manage human error. They were developed mainly in the US nuclear industry and vary in content/name by the consultant/organization that offers them. Common tools include:

  • Procedure Use*
  • Place Keeping*
  • Pre-Job Brief*
  • Post-Job Brief
  • Peer Checking*
  • STAR
  • Time Out
  • Rule of Three
  • 3-Way Communication*
  • Observation & Coaching*
  • Questioning Attitude
  • Attention to Detail
  • Errors Traps/Precursors

Here are some links to learn more about the tools above:

Also, if you plan on attending the 2014 Global TapRooT® Summit, attend Mark Paradies’ talk on human performance tools to learn more about these tools.

The asterisk (*) techniques above have always been included on the Root Cause Tree® (part of the TapRooT® System) because they are supported by established human factors research. Post-Job Briefs are also a well-established best practice that isn’t included on the Root Cause Tree® because it would occur after an incident or as part of the normal performance improvement program. 


Some of the techniques seem like excellent best practices (paying attention, having a questioning attitude, STAR, and Time Out), but I haven’t been able to find scientific human factors research that supports their use. For example, the “Rule of Three” is supposedly supported by research in the aviation industry that three yellow lights (conditions that are worrisome but not enough to prevent a flight) are equal to one red light (a fight no-go indicator – for example weather that doesn’t meet the flight minimums). 

Because they seem like good ideas, you may decide to adopt them, but they may not work as intended in all cases. After all, research hasn’t tested their limits.

The final technique, Error Traps/Precursors seems to violate a couple of human factors principles and therefore should only be used with caution.


The concept behind Error Traps/Precursors is that certain human conditions are indicators of impending human error. If a person can self-monitor to detect the “error likely” human condition, he/she can then apply an appro-priate human performance tool to avoid (stop) the impending error. For example, if you notice that you are rushing, you could apply STAR.

What are these human conditions? The selection varies depending on the consultant that presents the technique, but they commonly include:

  • Hurry
  • High Workload
  • Stress
  • Multi-Tasking
  • Distractions
  • Interruptions
  • Fatigue/Illness
  • Boredom
  • Habits
  • Complacency
  • Assumptions
  • Unexpected
  • Non-Routine
  • Changes
  • New Tasks
  • First Time
  • New Technique
  • Unclear/Unknown

A problem with this technique is that the person performing work must self-monitor to detect the human condition to self-trigger action. I’ve never seen research that people are particularly good at self-monitoring to detect any human condition. And even if they were, the list seems to indicate that people would be would be constantly self-triggering. By this list, people are always just about to make a mistake. (To err is human?)

Constantly monitoring points to another human factors limitation. The human brain automatically apportions a very limited resource – attention. Your brain continuously, subconsciously decides what to pay attention to and what to ignore. Your brain decides what sounds are important and which ones are noise. Your brain may decide that motion in the visual field deserves more attention than a stationary object. Or that a sharp pain is more important than a faint touch.

In times of crisis or when one is busy, your ability to pay attention is stressed. Imagine yourself driving on ice. You are so focused on the feel of the road and preventing sliding that you don’t have enough attention left over to even have a casual conversation.

Even when you are not stressed, if you self-monitor your state, you stealing attention from some other task. What faint signal might you miss?





All of the Human Performance Tools have a common limitation. They are weak corrective actions. They are 5’s or 6’s on the TapRooT® hierarchy of controls. Rules, procedures, training, are all attempts at improving human performance. And the human may be your weakest safeguard. If your human performance improvement program is based on the weakest safeguards, what should you expect? 

This doesn’t mean that you should not try proven human performance tools. It means that you should try to adopt stronger safeguards and understand the limitations of human performance tools and, at a minimum, implement defense in depth to ensure adequate performance.

Join the TapRooT® Root Cause Analysis Users & Friends Group on LinkedIn

March 18th, 2014 by

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Maybe it’s time for you to join the 2330 members of the TapRooT® Root Cause Analysis Users & Friends Group on LinkedIn. It’s a great place to network with other TapRooT® Users, ask questions, anmd keep up with the latest TapRooT® Information.

You can set your group profile to receive an e-mail every time something is posted, daily, weekly, or never. 

If you are a LinkedIn member, click on the link below to see the group:

Monday Accident & Lessons Learned: Worker Killed in Accident Aboard Nuclear Sub in India

March 17th, 2014 by

One worker was killed and two were injured aboard a nuclear submarine under construction in India.

Was it some high tech nuclear accident? No. I was a simple pressure test of a hydraulic tank. 

This accident once again shows that failure to control simple energy is often the cause of fatalities.

See the whole story here:

Could this accident have been prevented? Yes. How? Find out at the Proactive Use of TapRooT® Course being held on April 7-8. 

What if You Missed a Meeting that Could Have Prevented Someone’s Death?

March 16th, 2014 by


What if you missed a meeting that could have prevented someone’s death? Or what if you lost your job because you didn’t attend? Or your company lost millions of dollars simply because you didn’t attend a three-day meeting.

Would you make sure that you were there?

Sometimes that what I think about when someone says they just can’t attend this year’s Global TapRooT® Summit. Why? Because people have told me about the improvements in safety practices that they have learned about at the Summit that helped them save lives at their company. They told me how they applied best practices that they learned at the Summit to save their company millions of dollars. And they told me how the ideas they brought back from the Summit helped them looked good in front of their bosses and get promoted.

You might think that missing just one year isn’t that big of a deal … But that would be wrong. Every year the Summit is different. Every year there are different best practices discussed and leading edge practices presented. If you miss a year you might miss the best practice that could have helped you save a life in the following year. And even if that topic was repeated at a future Summit, that chance to save that life has been lost.

But how can you get your boss to approve attending (especially when the Summit is less than a month away)? They need to see the value and see that they too need the ideas that you will bring back. See the Summit brochure attached to the end of this newsletter and find the topics that will help you solve some of the toughest problems at your site. Then show your boss and explain that the company just can’t miss this valuable information. That should make the decision easy.

An intangible that you may not be considering is the motivation that you will get at the Global TapRooT® Summit. Have you thought about how much change you can make happen when you are motivated compared to being de-motivated? The Global TapRooT® Summit will help you revive your spirits and resume the battle to improve performance despite the obstacles. Register today! See:

It Takes a Team to Achieve World Class Performance Improvement

March 12th, 2014 by



Can the CEO alone make his company world class? No.

Can a Safety Manager make the safety culture world class all by himself? No.

Can a Maintenance Manager achieve world class equipment reliability without help? No.

It takes a team to make world class performance improvement happen. 

Senior management, middle management, supervisors, and shop floor employees all have a role to play to make world class performance a reality.

Would you like to learn more about what it takes to develop a world class performance improvement program? Attend the 2014 Global TapRooT® Summit and hear Mark Paradies, President of System Improvements and co-developer of the TapRooT® System, share what he’s learned from sources around the world about implementing  world class performance improvement. 

To be even more effective, bring a team to the Summit. Senior managers, the performance improvement sponsor, the performance improvement manager, incident investigators and problem troubleshooters, and shop floor workers that can help lead the charge to making your company’s performance improvement program world class.

Get more Summit info at:

See the complete Summit schedule at:

And register at:

Is Your Root Cause Analysis Adequate? Root Cause Network™ Newsletter, March 2014, Issue 120

March 3rd, 2014 by

How do you know if your root cause analysis is adequate? Read the article on page 3 of the March Root Cause Network™ Newsletter and find out! Download your copy of the newsletter by clicking on this link: Mar14NL120.pdf


.What else can you learn in this edition?

  • What’s Right and What’s Wrong with Human Performance Tools (Page 1)
  • Why Do Supervisors Produce Bad Investigations? (Page 2)
  • How Should You Target Your Investigations? (Page 2)
  • What’s Wrong with Your Trending? (Page 2)
  • Admiral Rickover’s Face-the-Facts Philosophy (Page 2)
  • Proactive Use of TapRooT® (Page 3)
  • Stop Slips, Trips, and Falls (Page 3)
  • Risk Management Best Practices (Page 3)
  • Upcoming TapRooT® Courses Around the World (Page 4)
  • What Can You Learn at the 2014 Global TapRooT® Summit? (Page 5, 6, & 7)

Plus there’s more! An article you really should read and act upon. See the article on Page 3: “Are you Missing an Important Meeting?

Why should you read that article among all the others? Here’s the first paragraph …

What if you missed a meeting and it caused someone to die. Or maybe you lost your job if you weren’t there? Or your company lost millions of dollars because you simply didn’t attend a three-day meeting. Would you make sure that you were there?

If those questions don’t grab your attention, what will?

Go to this link:


Print the March Root Cause Network™ Newsletter and read it from cover to cover!

You’ll be glad you did. (And you’ll find that there are several actions you will be compelled to take.)

Root Cause Analysis Tip: Improve Your Incident Investigations and Root Cause Analysis

February 27th, 2014 by

If you are a TapRooT® User, you are already have improved your root cause analysis and incident investigation just by attending TapRooT® Training. But what can you do to get even better? To improve beyond your initial TapRooT® Training? To make your company’s incident investigations and root cause analysis world-class?


 And choose the Incident Investigation & Root Cause Analysis Best Practices Track. What’s in the track?


  • Advanced Causal Factor Development (Ken Turnbull)
  • Interviewing: De-Coding Non-Verbal Behavior (Barb Phillips)
  • Getting Your Root Cause Analysis PhD (Mark Paradies)
  • Expert Facilitation of Investigations Using the TapRooT® Software (Brian Tink)
  • Infamous Accident (Alan Smith, Alan Scot, & Harry Thorburn)
  • Measure Your RC System: The Good, The Bad, and The Ugly (Ralph Blessing & Brian Dolin)
  • Slips, Trips, & Falls: The Science Behind Walking (Robert Shaw)
  • The Business End of Equipment Reliability (Heinz Bloch)

 Plus you will hear great keynote speakers to give you practical improvement ideas and get you motivated to make change happen.


  • Christine Cashen – Why Briansorm When You Can Brain El Niño?
  • Carl Dixon – A Strange Way to Live
  • Mark Paradies – World Class Performance Improvement
  • Edward Foulke – Sweeping Workplace Safety Changes
  • Rocky Bleier – Be the Best You Can Be

 There’s more … Networking and FUN! From the opening “Name Game” to the closing charity golf tournament, we’ve designed the TapRooT® Summit to make it easy to meet and get to know new people that can help you learn important lessons that will help you improve performance at your facility. And we know that you learn more when you are having fun so this won’t be a stuffy technical meeting that puts you to sleep. You will be involved and motivated.

Want to get even more out of your Summit experience? Then attend of the advanced pre-Summit Courses. I would recommend one of these if you are interested in making your TapRooT® implementation even better:


And you don’t have to worry that you will waste your time at the TapRooT®∞ Summit. We GUARANTEE your experience.

Attend the Summit and go back to work and use what you’ve learned.
If you don’t get at least 10 times the return on your investment,
simply return the Summit materials and we’ll refund the entire Summit fee.

With a guarantee like this one, you have nothing to lose and everything to gain!

Don’t procrastinate! Register today and be one step closer to the world-class incident investigation  and root cause analysis process that you know your company needs.

OSHA Requests Comments on Changes to the Process Safety Management Regulation

February 27th, 2014 by

Here’s a link to the Federal Register request for comments:

Interestingly, OSHA says:

While the PSM standard has been effective in improving process safety in the United States and protecting workers from many of the hazards associated with uncontrolled releases of highly hazardous chemicals, major incidents have continued to occur.

It then goes on to list some of the many serious process safety accidents that have occurred after the regulation had plenty of time to be effective.

What does it mean when a regulation is put in place to stop accidents and the accidents continue? Either the regulation is ineffective or the enforcement is ineffective.

In my review of the regulation and comparing it to Admiral Rickover’s successful process (nuclear) safety program, I concluded that there are many gaping holes in the regulation that, even if enforcement was effective, would have allowed the accidents mentioned to occur.

However, I believe that it is doubtful that OSHA will adopt the tough stance that Rickover required to ensure safe operations of the Navy’s nuclear power plants.


To learn more about Admiral Rickover’s approach to process safety, see the links provided here:

Make sure that you scroll down because there are many interesting articles and videos.

Then return here to leave your comments about your concerns/recommendations about the revision of the OSHA Process Safety Management standard.

How Do You Use Your Root Cause Analysis Data?

February 14th, 2014 by


I was at a meeting last week and the topic came up about how people used their root cause analysis data. To my surprise, about half the companies represented didn’t have a way to produce any type of graphs. The other half could produce pie charts using Microsoft Excel. There were one or two other people who had other ways to look at their data that they manually put into a system of some sort.

That got me thinking:

How do readers of this e-Newsletter use their root cause analysis data?

So I established this poll so that people could respond.

Click on the comments link below (and then scroll down to the comments box) and just let me know what you do.

After a week or two I will compile the data and report it in another e-Newsletter post.

Pass this on to others you know and let’s see how many people we can get to comment.

- – - -

How do you use your root cause analysis data:

1) We don’t have a way to collect our data across the site/company so we don’t use it.

2) We collect the data but don’t have a way to present it graphically.

3) We collect the data and put it in Excel and produce pie charts.

4) We collect the data and put it in Excel and produce Pareto Charts and X mR Charts.

5) We collect the data and put it in Excel and produce other types of charts (please list them).

6) We use TapRooT® Software but I haven’t thought about how to use our data.

7) We use TapRoot® Software and use the charting function in it to analyze our data.

8) We use other software and use it to trend our data using charts (please list software and chart types)

9) Other (tell us what you do)

- – - -

One more note:

Screen Shot 2014 02 14 at 11 24 53 AMIf you would like to learn the trending methods that we recommend after considerable research into trending best practices, you can:

a) Read Chapter 5 pf the TapRooT® Book.

b) Attend the 2-Day Advanced Trending Techniques Course on April 7-8 that is being held just before the 2014 Global TapRooT® Summit (just outside Austin, TX).

 c) Attend the 2014 Global TapRooT® Summit and see the latest trending features being built into the TapRooT® Software.

Did You get Your January Newsletter?

January 30th, 2014 by

We have started a new method of delivering the formerly “paper” Root Cause Network™ Newsletter. In the past you either received it by mail or as a PDF attachment to an e-mail. Now we will be including as one of the items in the TapRooT® Experts & Friends e-Newsletter.

So watch for the special edition of the e-Newsleller that includes a link to the Root Cause Network™ Newsletter every two months. We’ll include a list of the topics in the Root Cause Network™ Newsletter as part of the President’s Note (the first topic in the TapRooT® Experts & Friends e-Newsletter).

The topics in the January Root Cause Network™ Newsletter are:

  • What Do You Need to Perfect Your 2014 Improvement Program? (Page 1)
  • What Is Your Commitment to Safety? (Page 2)
  • Benchmarking Improvement Programs (Page 2)
  • Generate Improvement Team Spirit (Page 2)
  • Dilbert Cartoon (Page 2)
  • 2014 Global TapRooT® Summit Info (Page 3)
  • Why Trend? (Page 3)
  • Special Pre-Summit Courses (Page 3)
  • Why Are Accident Causes the Same Around the World? (Page 4)
  • International Networking (Page 4)
  • Upcoming International TapRooT® Courses (Page 4)
  • Pictures from TapRooT® Courses Around the World (Page 4)
  • Upcoming North American TapRooT® Courses (Page 5)
  • Pictures from Previous Global TapRooT® Summits (page 5)

Wow! That’s a lot of information. I would especially recommend the first article - 

What Do You Need to Perfect Your 2014 Improvement Program?

But there are lot’s of other items that deserve a few minutes of your time.

If you didn’t receive your newsletter, you can download it by clicking on the link below or by going to THIS LINK.


What Admiral Rickover Had to Say About Management

January 9th, 2014 by

(Picture of Captain Rickover taken after WWII while he was learning about nuclear technology
at the Manhattan Project before he became head of the Navy nuclear power program.)

The following is the text of a speech delivered in 1982 by Admiral Hyman G. Rickover – the father of the Nuclear Navy – at Columbia University. Rickover’s accomplishments as the head of the Nuclear Navy are legendary. From developing the first power producing submarine based nuclear reactor from scratch to operations in just three years to creating a program to guarantee process safety (nuclear safety) for over 60 years (zero nuclear accidents).

I am reprinting this speech here because I believe that many do not understand the management concepts needed to guarantee process safety. We teach these concepts in our “Reducing Serious Injuries and Fatalities Using TapRooT®” pre-Summit course. Since many won’t be able to attend this training, I wanted to give all an opportunity to learn these valuable lessons by posting this speech.

- – -

Human experience shows that people, not organizations or management systems, get things done. For this reason, subordinates must be given authority and responsibility early in their careers. In this way they develop quickly and can help the manager do his work. The manager, of course, remains ultimately responsible and must accept the blame if subordinates make mistakes.

As subordinates develop, work should be constantly added so that no one can finish his job. This serves as a prod and a challenge. It brings out their capabilities and frees the manager to assume added responsibilities. As members of the organization become capable of assuming new and more difficult duties, they develop pride in doing the job well. This attitude soon permeates the entire organization.

One must permit his people the freedom to seek added work and greater responsibility. In my organization, there are no formal job descriptions or organizational charts. Responsibilities are defined in a general way, so that people are not circumscribed. All are permitted to do as they think best and to go to anyone and anywhere for help. Each person then is limited only by his own ability.

Complex jobs cannot be accomplished effectively with transients. Therefore, a manager must make the work challenging and rewarding so that his people will remain with the organization for many years. This allows it to benefit fully from their knowledge, experience, and corporate memory.

The Defense Department does not recognize the need for continuity in important jobs. It rotates officer every few years both at headquarters and in the field. The same applies to their civilian superiors.

This system virtually ensures inexperience and nonaccountability. By the time an officer has begun to learn a job, it is time for him to rotate. Under this system, incumbents can blame their problems on predecessors. They are assigned to another job before the results of their work become evident. Subordinates cannot be expected to remain committed to a job and perform effectively when they are continuously adapting to a new job or to a new boss.

When doing a job—any job—one must feel that he owns it, and act as though he will remain in the job forever. He must look after his work just as conscientiously, as though it were his own business and his own money. If he feels he is only a temporary custodian, or that the job is just a stepping stone to a higher position, his actions will not take into account the long-term interests of the organization. His lack of commitment to the present job will be perceived by those who work for him, and they, likewise, will tend not to care. Too many spend their entire working lives looking for their next job. When one feels he owns his present job and acts that way, he need have no concern about his next job.

In accepting responsibility for a job, a person must get directly involved. Every manager has a personal responsibility not only to find problems but to correct them. This responsibility comes before all other obligations, before personal ambition or comfort.

A major flaw in our system of government, and even in industry, is the latitude allowed to do less than is necessary. Too often officials are willing to accept and adapt to situations they know to be wrong. The tendency is to downplay problems instead of actively trying to correct them. Recognizing this, many subordinates give up, contain their views within themselves, and wait for others to take action. When this happens, the manager is deprived of the experience and ideas of subordinates who generally are more knowledgeable than he in their particular areas.

A manager must instill in his people an attitude of personal responsibility for seeing a job properly accomplished. Unfortunately, this seems to be declining, particularly in large organizations where responsibility is broadly distributed. To complaints of a job poorly done, one often hears the excuse, “I am not responsible.” I believe that is literally correct. The man who takes such a stand in fact is not responsible; he is irresponsible. While he may not be legally liable, or the work may not have been specifically assigned to him, no one involved in a job can divest himself of responsibility for its successful completion.

Unless the individual truly responsible can be identified when something goes wrong, no one has really been responsible. With the advent of modern management theories it is becoming common for organizations to deal with problems in a collective manner, by dividing programs into subprograms, with no one left responsible for the entire effort. There is also the tendency to establish more and more levels of management, on the theory that this gives better control. These are but different forms of shared responsibility, which easily lead to no one being responsible—a problems that often inheres in large corporations as well as in the Defense Department.

When I came to Washington before World War II to head the electrical section of the Bureau of Ships, I found that one man was in charge of design, another of production, a third handled maintenance, while a fourth dealt with fiscal matters. The entire bureau operated that way. It didn’t make sense to me. Design problems showed up in production, production errors showed up in maintenance, and financial matters reached into all areas. I changed the system. I made one man responsible for his entire area of equipment—for design, production, maintenance, and contracting. If anything went wrong, I knew exactly at whom to point. I run my present organization on the same principle.

A good manager must have unshakeable determination and tenacity. Deciding what needs to be done is easy, getting it done is more difficult. Good ideas are not adopted automatically. They must be driven into practice with courageous impatience. Once implemented they can be easily overturned or subverted through apathy or lack of follow-up, so a continuous effort is required. Too often, important problems are recognized but no one is willing to sustain the effort needed to solve them.

Nothing worthwhile can be accomplished without determination. In the early days of nuclear power, for example, getting approval to build the first nuclear submarine—the Nautilus—was almost as difficult as designing and building it. Many in the Navy opposed building a nuclear submarine.

In the same way, the Navy once viewed nuclear-powered aircraft carriers and cruisers as too expensive, despite their obvious advantages of unlimited cruising range and ability to remain at sea without vulnerable support ships. Yet today our nuclear submarine fleet is widely recognized as our nation’s most effective deterrent to nuclear war. Our nuclear-powered aircraft carriers and cruisers have proven their worth by defending our interests all over the world—even in remote trouble spots such as the Indian Ocean, where the capability of oil-fired ships would be severely limited by their dependence on fuel supplies.

The man in charge must concern himself with details. If he does not consider them important, neither will his subordinates. Yet “the devil is in the details.” It is hard and monotonous to pay attention to seemingly minor matters. In my work, I probably spend about ninety-nine percent of my time on what others may call petty details. Most managers would rather focus on lofty policy matters. But when the details are ignored, the project fails. No infusion of policy or lofty ideals can then correct the situation.

To maintain proper control one must have simple and direct means to find out what is going on. There are many ways of doing this; all involve constant drudgery. For this reason those in charge often create “management information systems” designed to extract from the operation the details a busy executive needs to know. Often the process is carried too far. The top official then loses touch with his people and with the work that is actually going on.

Attention to detail does not require a manager to do everything himself. No one can work more than twenty-four hours each day. Therefore to multiply his efforts, he must create an environment where his subordinates can work to their maximum ability. Some management experts advocate strict limits to the number of people reporting to a common superior—generally five to seven. But if one has capable people who require but a few moments of his time during the day, there is no reason to set such arbitrary constraints. Some forty key people report frequently and directly to me. This enables me to keep up with what is going on and makes it possible for them to get fast action. The latter aspect is particularly important. Capable people will not work for long where they cannot get prompt decisions and actions from their superior.

I require frequent reports, both oral and written, from many key people in the nuclear program. These include the commanding officers of our nuclear ships, those in charge of our schools and laboratories, and representatives at manufacturers’ plants and commercial shipyards. I insist they report the problems they have found directly to me—and in plain English. This provides them unlimited flexibility in subject matter—something that often is not accommodated in highly structured management systems—and a way to communicate their problems and recommendations to me without having them filtered through others. The Defense Department, with its excessive layers of management, suffers because those at the top who make decisions are generally isolated from their subordinates, who have the first-hand knowledge.

To do a job effectively, one must set priorities. Too many people let their “in” basket set the priorities. On any given day, unimportant but interesting trivia pass through an office; one must not permit these to monopolize his time. The human tendency is to while away time with unimportant matters that do not require mental effort or energy. Since they can be easily resolved, they give a false sense of accomplishment. The manager must exert self-discipline to ensure that his energy is focused where it is truly needed.

All work should be checked through an independent and impartial review. In engineering and manufacturing, industry spends large sums on quality control. But the concept of impartial reviews and oversight is important in other areas also. Even the most dedicated individual makes mistakes—and many workers are less than dedicated. I have seen much poor work and sheer nonsense generated in government and in industry because it was not checked properly.

One must create the ability in his staff to generate clear, forceful arguments for opposing viewpoints as well as for their own. Open discussions and disagreements must be encouraged, so that all sides of an issue will be fully explored. Further, important issues should be presented in writing. Nothing so sharpens the thought process as writing down one’s arguments. Weaknesses overlooked in oral discussion become painfully obvious on the written page.

When important decisions are not documented, one becomes dependent on individual memory, which is quickly lost as people leave or move to other jobs. In my work, it is important to be able to go back a number of years to determine the facts that were considered in arriving at a decision. This makes it easier to resolve new problems by putting them into proper perspective. It also minimizes the risk of repeating past mistakes. Moreover if important communications and actions are not documented clearly, one can never be sure they were understood or even executed.

It is a human inclination to hope things will work out, despite evidence or doubt to the contrary. A successful manager must resist this temptation. This is particularly hard if one has invested much time and energy on a project and thus has come to feel possessive about it. Although it is not easy to admit what a person once thought correct now appears to be wrong, one must discipline himself to face the facts objectively and make the necessary changes—regardless of the consequences to himself. The man in charge must personally set the example in this respect. He must be able, in effect, to “kill his own child” if necessary and must require his subordinates to do likewise. I have had to go to Congress and, because of technical problems, recommended terminating a project that had been funded largely on my say-so. It is not a pleasant task, but one must be brutally objective in his work.

No management system can substitute for hard work. A manager who does not work hard or devote extra effort cannot expect his people to do so. He must set the example. The manager may not be the smartest or the most knowledgeable person, but if he dedicates himself to the job and devotes the required effort, his people will follow his lead.

The ideas I have mentioned are not new—previous generations recognized the value of hard work, attention to detail, personal responsibility, and determination. And these, rather than the highly-touted modern management techniques, are still the most important in doing a job. Together they embody a common-sense approach to management, one that cannot be taught by professors of management in a classroom.

I am not against business education. A knowledge of accounting, finance, business law, and the like can be of value in a business environment. What I do believe is harmful is the impression often created by those who teach management that one will be able to manage any job by applying certain management techniques together with some simple academic rules of how to manage people and situations.

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