Category: Performance Improvement

Root Cause Tip: Luck Versus Being Consistent, Success and Failure Can Come From Both

March 14th, 2018 by

Every best practice can be a strength or a weakness. Even one phrase like “I will ____” can be self-defeating or uplifting. “I will succeed” versus “I will fail.” Both phrases set your compass for success or failure. Okay, so what does philosophy have to do with root cause analysis? Simple….

Practice safe behaviors, build and sustain safe and sustainable processes with good best practices, and success is measured by less injuries, less near-misses, and more efficient processes.

Practice unsafe behaviors, build unsafe but sustainable processes with poor best practices, and success is measured by more injuries, more near-misses, and wasteful business processes. Safety only happens by luck!

Guess what? In many cases, you can still be in compliance during audits but still meet the criteria of “unsafe but sustainable processes with poor best practices . . . measured by more injuries, more near-misses, and wasteful business processes.”

This is why Question Number 14 on the TapRooT® Root Cause Tree® is so important.

Not every Causal Factor/Significant Issue that occurred during an incident or was found during an audit is due to a person just breaking a rule or taking shortcuts. In many cases, the employee was following the rules to the “T” when the action that the employee performed, got him/her hurt or got someone else hurt.

Take time to use the TapRooT® Root Cause Tree®, Root Cause Tree® Dictionary, and Corrective Action Helper® as designed to perform consistently with a successful purpose.

Want to learn more? Attend one of our public TapRooT® Courses or contact us to schedule an onsite course.

Hire a Professional

March 12th, 2018 by

root cause analysis, RCA, investigation










I know every company is trying to do the best they can with the resources that are available. We ask a lot of our employees and managers, trying to be as efficient as we can.
However, sometimes we need to recognize when we need additional expertise to solve a particular problem. Or, alternatively, we need to ensure that our people have the tools they need to properly perform their job functions.  Companies do this for many job descriptions:

  • Oil analyst
  • Design engineer
  • Nurse
  • Aircraft Mechanic

I don’t think we would ask our Safety Manager to repair a jet engine.  THAT would be silly!

However, for some reason, many companies think that it is OK to ask their aircraft mechanics to perform a root cause analysis without giving them any additional training.  “Looks like we had a problem with that 737 yesterday.  Joe, go investigate that and let me know what you find.”  Why would we expect Joe, who is an excellent mechanic, to be able to perform a professional root cause analysis without being properly trained?  Would we send our Safety Manager out to repair a jet engine?

It might be tempting to assume that performing an RCA is “easy,” and therefore does not require professional training.  This is somewhat true.  It is easy to perform bad RCA’s without professional training.  While performing effective  investigations does not require years of training, there is a certain minimum competency you should expect from your team, and it is not fair to them to throw them into a situation which they are not trained to handle.

Ensure you are giving your team the support they need by giving them the training required to perform excellent investigations.  A 2-Day TapRooT® Essential Techniques Course is probably all your people will need to perform investigations with terrific results.


What does bad root cause analysis cost?

March 7th, 2018 by


Have you ever thought about this question?

An obvious answer is $$$BILLIONS.

Let’s look at one example.

The BP Texas City refinery explosion was extensively investigated and the root cause analysis of BP was found to be wanting. But BP didn’t learn. They didn’t implement advanced root cause analysis and apply it across all their business units. They didn’t learn from smaller incidents in the offshore exploration organization. They didn’t prevent the BP Deepwater Horizon accident. What did the Deepwater Horizon accident cost BP? The last estimate I saw was $22 billion. The costs have probably grown since then.

I would argue that ALL major accidents are at least partially caused by bad root cause analysis and not learning from past experience.

EVERY industrial fatality could be prevented if we learned from smaller precursor incidents.

EVERY hospital sentinel event could be prevented (and that’s estimated at 200,000 fatalities per year in the US alone) if hospitals applied advanced root cause analysis and learned from patient safety incidents.

Why don’t companies and managers do better root cause analysis and develop effective fixes? A false sense of saving time and effort. They don’t want to invest in improvement until something really bad happens. They kid themselves that really bad things won’t happen because they haven’t happened yet. They can’t see that investing in the best root cause analysis training is something that leads to excellent performance and saving money.

Yet that is what we’ve proven time and again when clients have adopted advanced root cause analysis and paid attention to their performance improvement efforts.

The cost of the best root cause analysis training and performance improvement efforts are a drop in the bucket compared to any major accident. They are even cheap compared to repeat minor and medium risk incidents.

I’m not promising something for nothing. Excellent performance isn’t free. It takes work to learn from incidents, implement effective fixes, and stop major accidents. Then, when you stop having major accidents, you can be lulled into a false sense of security that causes you to cut back your efforts to achieve excellence.

If you want to learn advanced root cause analysis with a guaranteed training, attend of our upcoming public TapRooT® Root Cause Analysis Training courses.

Here is the course guarantee:

Attend the course. Go back to work and use what you have learned to analyze accidents,
incidents, near-misses, equipment failures, operating issues, or quality problems.
If you don’t find root causes that you previously would have overlooked
and if you and your management don’t agree that the corrective actions that you
recommend are much more effective, just return your course materials/software
and we will refund the entire course fee.

Don’t be “penny wise and pound foolish.” Learn about advanced root cause analysis and apply it to save lives, prevent environmental damage, improve equipment reliability, and achieve operating excellence.

Highlights from the 2018 Global TapRooT® Summit

March 5th, 2018 by

IMG 7328

Coming up with a highlight reel from the 2018 Global TapRooT® Summit is almost impossible. I always think that the Summit just can’t get any better and then we outdo ourselves planning the next one. Here are some highlights followed by the top six items attendees shared that they needed to do better at their facilities.

First, a video to share the experience…

By the way, the next Global TapRooT® Summit is scheduled for March 11-15, 2019, in Houston (Montgomery, TX) at the La Torretta Lake Resort & Spa (picture below).

Screen Shot 2018 03 05 at 11 54 44 AM

Now for my impressions of the highlights …

First, the Keynote Speakers were outstanding.

We started with Dr. Carol Gunn who gave an inspiring talk about medical errors and how to encourage error reporting and effective investigations. Carol is a TapRooT® User and medical doctor … she knows what she is talking about.

Next, we had an UNBELIEVABLE talk by Boaz Rauchwerger who told us all to take a positive approach to improvement.

IMG 7342

The final keynote on Wednesday was Inky Johnson. How can I explain how he inspired us? There was a long line of people who just came up to thank Inky and get their picture taken with him. If you don’t know Inky’s story. watch it below for motivation to accomplish more in life.


After Inky’s keynote, Carl Dixon entertained us at the Summit Reception. Here I am singing Proud Mary with him…


On Thursday, I was the opening keynote and concluded with a TapRooT® Implementation Gap Analysis. People shared where they needed to improve their TapRooT® implementation. What were the top 6 items they needed to do better?

  1. Use advanced root cause analysis (TapRooT®) for both reactive and proactive investigations.
  2. Use an investigation rewards program more effectively.
  3. Guide their improvement programs through management’s use of performance measures and advanced trending techniques.
  4. Proactive improvement that drives improvement success (tie with 5).
  5. Develop a leadership succession plan.
  6. Communicate improvement accomplishments successfully.

These items will help us plan sessions for next year’s Summit.

Screen Shot 2018 03 05 at 1 39 03 PM

Vincent Phipps closed out the day with his discussion of the four personality types and how to use them to communicate more effectively.

On Friday we started with the session that helped attendees develop plans to fill their program gaps (started with the gap analysis performed on Thursday).

IMG 7338


Then, I (Mark Paradies) interviewed Mike Williams about his experiences when the Deepwater Horizon experienced a blowout, explosion(s), and fire. Wow! What an experience. People were sitting on the edge of their seats as Mike answered my questions and all the questions from the Summit participants. We actually ran over the finish time by 15 minutes as people asked interesting questions. The lessons learned from this one session about emergency response, investigations, and safety were … UNBELIEVABLE! I learned several things about the accident that I didn’t know from the various reports (CSB, Presidential Commission, BP, or Coast Guard) that added to my understanding of the Causal Factors and root causes. There was also an important lesson for investigators about empathy and PTSD after a major accident.

And that’s just a summary of the Keynote Speakers impact. There were also some great Best Practice Sharing sessions and speakers. My favorite was the TapRooT® Users Share Best Practices Session (soon, you will be seeing videos from this session to share some of the best practices).

Here are what some TapRooT® Users had to say about their 2018 Global TapRooT® Summit experience…


What a Summit! Hope to see you in Houston in 2019!

Nuclear Plant Fined $145,000 for “Gun-Decked Logs”

February 21st, 2018 by

When I was in the Navy, people called it “gun-decking the logs.”

In the Navy this means that you falsify your record keeping … usually by just copying the numbers from the previous hour (maybe with slight changes) without making the rounds and taking the actual measurements. And if you were caught, you were probably going to Captain’s Mast (disciplinary hearing).

The term “gun-decking” has something to do with the “false” gun deck that was built into British sailing ships of war to make them look like they had more guns. Sometimes midshipmen would falsify their navigation training calculations by using dead reckoning to calculate their position rather than using the Sun and the stars. This might have been called “gun-decking” because the gun deck is where they turned their homework over to the ships navigator to be reviewed.


What happened at the Nuke Plant? A Nuclear Regulatory Commission inspector found that 13 operators had gun-decked their logs. Here’s a quote from the article describing the incident:

“An NRC investigation, completed August 2017, found that on multiple occasions during the three-month period, at least 13 system operators failed to complete their rounds as required by plant procedures, but entered data into an electronic log indicating they had completed equipment status checks and area inspections,” the NRC said in a statement.”

What was the corrective action? The article says:

“The plant operator has already undertaken several corrective actions, the NRC said, including training for employees, changes in the inspection procedures and disciplinary measures for some staff.”

Hmmm … training, procedures, and discipline. That’s the standard three corrective actions. (“Round up the usual suspects!”) Even problems that seem to be HR issues can benefit from advanced root cause analysis. Is this a Standards, Policy, and Administrative Controls Not Used issue? Is there a root cause under that Near Root Cause that needs to be fixed (for example, Enforcement Needs Improvement)? Or is discipline the right answer? It would be interesting to know all the facts.

Want to learn to apply advanced root cause analysis to solve these kinds of problems? Attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Courses. See the upcoming public courses by CLICKING HERE. Or CLICK HERE to contact us about having a course at your site.

What is the Fastest Way to Get Fired After an Accident?

February 7th, 2018 by

If you work at a blame-oriented company, the answer to the question above is easy. Just admit that you were the last person to touch whatever went wrong that caused the accident.

Or, if you are in the Navy, all you have to do is to be the CO of a ship that has a collision at sea.

A slower way to get fired is to be the Plant Manager or Division Manager who doesn’t have good answers when he or she is asked by the corporate VP, “What are you going to do to prevent a repeat accident in the future?” Actually, they probably don’t fire someone this high in the organization. Rather, they transfer them to a staff job where they are never heard from again.

What is the best way to avoid being fired? Don’t have the accident in the first place! Instead, have a proactive improvement program that identifies problems, finds their root causes, and effectively fixes them before an accident happens.

Want to learn more about using TapRooT® in a proactive improvement program? Attend Dave Janney’s pre-Summit course: TapRooT® for Audits.

What’s covered in the course?


  • TapRooT® Process Introduction and Initial Audit
  • SnapCharT® and Exercise
  • Significant Issues and Exercise
  • Root Cause Tree® and Exercise
  • Generic Causes
  • Corrective Actions and Exercise


  • The Root Cause Tree® and Preparing for Audits with Root Cause Exercise
  • Audit Programs, Trend and Process Root Cause Analysis
  • TapRooT® Software Introduction
  • Frequently Asked Questions about TapRooT®
  • Final Audit Observation Exercise

Don’t miss this course coming up quickly on February 27-27 in Knoxville, TN. Register by CLICKING HERE.


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

Where Do You Get Ideas To Improve Root Cause Analysis?

January 31st, 2018 by

When I was assigned the job of figuring out how to improve investigations and root cause analysis … I knew that we were NOT finding the causes of human errors. But where would I get ideas to help make things better? The year was 1985 and there wasn’t an easy place to start …

  • no internet
  • no e-mails with upcoming courses
  • no conferences on the topic (maybe one talk at a nuclear industry conference’s breakout session)

I knew that the Institute for Nuclear Power Operations was working on a system because they had tried to hire me to help create it.

So what did I do?

  • Started looking at the human factors research.
  • Networked with the folks I knew at our corporate headquarters, INPO, the University of Illinois, INEL, EPRI, and several utilities where I knew people.
  • Started trying to create a list of causes that encompassed the human factors research that I was familiar with.

This lead to a beginning system to find root causes that, eventually, led to the development of TapRooT® Root Cause Analysis System.

It was a long road with many lessons learned.

In 1988, we started System Improvements to help people improve their root cause analysis systems. In 1990, we won a contract to help the US Nuclear Regulator Commission improve their analysis of human errors. In 1991 we started working with our first oil and chemical company (Chevron) to improve their root cause analysis as part of their efforts to improve process safety. From there our growth into all types of industries with incidents – incidents that need fixes to prevent recurrence based on the real root causes – has been … pretty dramatic.

In 1994 we held the first TapRooT® Summit (not named the Summit until sometime later). It had great speakers and 35 attendees. I cooked steaks for everyone as our closing session.

Mark Ed 2

 1996 Summit Keynote Speaker with Mark Paradies (left)

Why did we decide to have a summit to focus on root cause analysis and performance improvement? Because I thought that our clients needed it. They needed:

  • a place to learn the latest ways to improve human performance.
  • to network and share best practices they were testing and perfecting.
  • to hear about what we were doing to improve the TapRooT® System.
  • motivation to keep them at the “performance improvement grindstone.”

L M Astronaut

Linda Under and Mark Paradies with 1997 Astronaut Keynote Speaker

Little did I know that this first conference would turn into an annual event that had hundreds of attendees who are some of the smartest people improving industrial safety, quality, patient safety, process safety, asset optimization, and operational excellence from around the world.


Linda Unger with Summit attendee from South Korea in 1998

I would never have guessed that I would draw people from Australia, Indonesia, Malaysia, UK, Saudi Arabia, Tanzania, New Zealand, Colombia, Brazil, Canada, Mexico, South Africa, Russia, Denmark, France, and many other countries (even the USA!) to hear what we thought others needed to learn to make their performance great.


People sharing best practices at the 2016 Global TapRooT® Summit

But it happened. And now, if someone asks:

“Where Do You Get Ideas To Improve Root Cause Analysis?”

The answer is … The Global TapRooT® Summit.

The next Summit is rapidly approaching. Where is it? It is being held in Knoxville, Tennessee, (our hometown) on February 26 – March 2.

Want to find out more about the 10 pre-Summit courses being held on February 26-27? CLICK HERE.

Want to find out more about the blockbuster talks being delivered by the Keynote Speakers? CLICK HERE.

Want to see a list of the Best Practice Presenters? CLICK HERE.

Want to see the schedules for all nine Summit Tracks? CLICK HERE.

But don’t spend too much time clicking. You need to REGISTER ASAP and get your hotel and travel plans finalized because you need to attend this Summit.

Watch this video to see what past Summit attendees have to say…

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.

Screen Shot 2018 01 25 at 10 01 23 AM

You can download the matrix that Jack uses here:

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

Interesting Article in “Stars & Strips” About Navy Court-Martials for COs Involved in Collisions

January 22nd, 2018 by

Screen Shot 2018 01 22 at 6 30 43 PM

The article starts with:

The Navy’s decision to pursue charges of negligent homicide against the former commanders of the USS Fitzgerald and USS John McCain has little precedent, according to a Navy scholar who has extensively scrutinized cases of command failure.”

See the whole article at:

The article implies that blame and shame is the normal process for COs whose ships are involved in accidents.

Isn’t it time for the US Navy to learn real advanced root cause analysis that can teach them to find and fix the causes of problems at cause collisions at sea?

Safety Fines Double in One Year in UK

January 18th, 2018 by

In the UK, fines related to safety doubled from 2016 to 2017. Here is a video from Safety & Health Practitioner (SHP) that provides more details…

Perhaps now is the time to invest in improved root cause analysis as part of your safety improvement efforts?

CLICK HERE for more information about TapRooT® Root Cause Analysis or CLICK HERE for information about TapRooT® Training.

CLICK HERE to see a list of public TapRooT® Courses in Europe.

CLICK HERE to contact us for information about training at your site.

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.

Why do people try to make root cause analysis so difficult?

January 17th, 2018 by


I read a comment string on LinkedIn about root cause analysis. People made the concepts and techniques so hard to understand.

First, there was an argument over what is a root cause. One person argued that there was no such thing because EVERY cause had another deeper cause. Someone else argued that there wasn’t a root cause because most incidents had multiple causes. Someone else introduced the idea of root causes, contributing causes, causal factors, and initiating events. Someone else brought up the concept of latent causes and Swiss cheese.

If that wasn’t enough disagreement, another side argument started over what was an incident, and accident, a near-miss, and a significant incident. This lead to a discussion of what needed investigation and how good an investigation was good enough.

At SI, we too had discussions about these topics 30 years ago. However, in the TapRooT® System, these arguments are settled and the terminology is either settled or irrelevant.

Perhaps it is my engineering and Nuclear Navy training that lead me away from philosophical discussions and turned me toward practical solutions to problems.

Perhaps it was my human factors training that made it easy to see why people made mistakes and what we could do to prevent them.

Perhaps it is my ability to take complex subjects and make them understandable that lead to the development of a systematic, practical, repeatable system to find the root causes of problems – the TapRooT® System.

So, if you are tired of debate and just want a system that has been proven around the world to find and fix the root causes of safety, quality, equipment, and production issues, learn about TapRooT® and save lot’s of time by avoiding needless arguments.

CLICK HERE to find out more about our 2-Day and 5-Day TapRooT® Training.

CLICK HERE to see where our upcoming public TapRooT® Training is being held.

Or CLICK HERE to contact us about having a course at your site.

Why are the SMARTEST people going to the 2018 Global TapRooT® Summit?

January 17th, 2018 by


About three Summits ago, I had a Summit attendee come up to me and say:

Mark, it is amazing the quality of speakers and topics you put together for the Summit.
But even more amazing is the networking. The people at this Summit are some of
the smartest people working on real life performance improvement in industry!
I just wanted to tell you thanks for making this happen.

 How do we get such high quality attendees? That’s the kind of people who use TapRooT® Root Cause Analysis to stop accidents, improve quality, reduce risk, and improve equipment reliability.

If you haven’t registered for the 2018 Global TapRooT® Summit yet, GET HOT! Visit the Summit web site and get registered TODAY!

Don’t Miss the TapRooT® Family Reunion

January 17th, 2018 by


The Global TapRooT® Summit was almost named the TapRooT® Family Reunion. Why? Because that’s the way it feels.

Friendly folks getting together to say hello and get reacquainted.

Unless you belong to a dysfunctional family, you know what I mean.

This family has a common goal. They to share best practices and learn how to achieve outstanding performance. TapRooT® Root Cause Analysis is a part of that effort. But there is so much more to learn and share at the reunion (Summit). And that’s why we sponsor the Summit and spend lavishly on speakers.

We want to provide the opportunity for our best clients to meet face to face, develop relationships, and get new ideas to make safety, quality, equipment reliability, patient and process safety, and productivity even better. And leave the Summit inspired to go back home and make performance great.

The learning that takes place is one of the reasons that we require Certified TapRooT® instructors to attend the Summit at least once every two years. We think that keeping up to date on the latest improvement ideas is that important.

So don’t miss the reunion (the Summit) and your chances to make your performance improvement efforts that much better. Register for the 2018 Global TapRooT® Summit (February 26 – March 2, Knoxville, TN) TODAY by CLICKING HERE.

Why does your site need someone (or a team) at the 2018 Global TapRooT® Summit?

January 10th, 2018 by


Since there are so many high-quality conferences and events put on each year, you really need to think about which ones you should go to. If you haven’t signed up for the 2018 Global TapRooT® Summit yet, here are four top reasons to attend.



You can’t afford a major accident, a fatality, a serious quality defect, a sentinel event or an unexpected equipment failure.

The TapRooT® Summit is a unique gathering of people intent on improving performance. They share ideas across companies, disciplines, and continents. The sharing of new ideas and best practices will help you develop ideas to stop accidents, fatalities, quality issues, sentinel events, and equipment failures.

What you may not have thought of is how much money this could save your company. Do you know the costs of human errors that occurred at your site? What were your workman’s comp costs? How much does unexpected downtime and lost production cost your site? What were the costs of legal issues due to mistakes and the resulting lawsuits? You will be far ahead financially if you stop just ONE major issue.


What will happen to your career is you are seen as an essential problem solver that leads the sites improvement efforts?

But where will you get the skills and ideas to lead improvement at your site? That’s easy. Attend the 2018 Global TapRooT® Summit.

When we plan the Summit we take the lessons we learn from teaching root cause analysis around the world and build sessions that we know will help solve frequently occurring issues that we have observed at courses. You will be surprised how many people face issues similar to the ones that you face and how there are people who have figured out how to improve performance and stop those problems. Don’t reinvent the wheel. Attend the Summit and learn from the success of others.


Improving performance requires constant attention. Working hard to constantly improve performance can wear you down. Where do you get the motivation to continually challenge the status quo? Attend the TapRooT® Summit!

Most people we talk to before the Summit say that they are attending to learn new skills and get new ideas and best practices to help their site improve performance. And after the Summit they agree that they learned valuable information well worth the time and expense of attended. But they are surprised that they got an unexpected benefit that was even more valuable. They left the Summit FIRED UP to go back to work and make things happen.

Why is motivation so valuable? Because an unmotivated person is unlikely to have the stamina to see an improvement effort through to completion. They get started but they don’t get things done.

We understand motivation and making improvements happen and that’s why we know that motivation is important. That’s why we build in events to motivate you throughout the Summit. Attend the 2018 Global TapRooT® Summit and go back to work CHARGED UP to make improvement happen.


What? How can fun be an important reason to attend the TapRooT® Summit? We have learned that people learn more, retain more, and bring more and better ideas back to work from the Summit if they have fun learning and sharing.

After all, who says that work and learning have to be dull and boring? We have discovered how to make the Summit an activity that you will find valuable and ENJOYABLE every time you attend.


Have you ever noticed how an effective team accomplishes much more than a single motivated individual?

That’s why we recommend that a site truly interested in achieving excellence send an improvement team to the TapRooT® Summit.

A team can spread out across the various sessions (there are tracks with various topics to pick from). Someone might attend the Safety Track while someone else attends the Quality Track, while someone else attends the Human Factors Track, while someone else attends the Asset Optimization Track. See the schedules for the various tracks by CLICKING HERE.


We know that you will find the 2018 Global TapRooT® Summit a valuable experience. We know that you will have a great return on your investment of time and money. And we provide you with this guarantee:

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.

So don’t wait. REGISTER TODAY!

Want to see what people who attend the Summit have to say after they attend? Here’s a video I made a few years ago and it sure is a blast from the past that still applies today…

Sorry, we won’t be having golf at this Summit (the first week in March in Tennessee just doesn’t work) but we will have a great reception and a lot of sharing.

Why Should I get the New TapRooT® Books?

January 9th, 2018 by

When someone calls me for help with an investigation, I often ask them what color TapRooT® Book they have. Sometimes they want to know..

What difference does it make what color my book is?

The answer is that it let’s me know how long ago they took TapRooT® Training and what version of the TapRooT® System they are using.  It is always sad to see people struggling with an issue we solved by improving TapRoot® and they just don’t know about the improvement.

Over the almost three decades that we have been developing TapRooT®, we have made major improvements. If you are still using the system that came in three-ring binders, you are back in the 1996 version of the system.

You might think that NOBODY would be using that outdated a version of the system but someone sent me a review of TapRooT® that they read and … sure enough … the review was of the 1996 book. So to people still using the three-ring binders: Update your documentation to the newest version and you will be shocked.

If you have the green book, you are working from the 2000 revision. You are working from a system from the same millennia. Update to the new version and you will jump ahead 16 years.

If you have the thick black book, you are working from the 2008 version. You too will be pleasantly surprised by what we have learned in the last eight years and how we have improved the usefulness of the TapRooT® Books.

And what is the latest version? These books are also black but there are  smaller and there are eight of them (currently book five and eight are still in production).

What do these books look like and how are they an improvement over the older 2008 book?

BOOKS 3 & 4


Above is the Investigation book set. It includes:

These are the books that cover using TapRooT® to find the root causes of everything from small/minor incidents to major accidents.

How are they an improvement over the older 2008 TapRooT® Book? Well … we took everything we have learned in the last eight years and used it to improve our documentation. And the first things we learned is … LESS IS MORE. That’s why we broke the books up into separate topics. You can just read what is applicable to what you are doing. But how specifically is the investigation set improved over the old book?

  • The set includes the latest Root Cause Tree® and Dictionary that make the system even better with improved definitions in the Dictionary and an new category (language) in the Communication Basic Cause Category.
  • The Essentials Book is a an easy read (only 100 pages long). It guides you through a new 5 step process that makes TapRooT® easy to use for simple investigations. This improves your simple investigations while saving time.
  • The Major Investigations Book explains the whole TapRooT® System and includes the traditional 7-Step Investigation Process. The book includes improved TapRooT® Techniques, detailed examples of each technique, and even better ideas to help you identify your Causal Factors before you start analyzing their root causes.
  • The set also references the latest TapRooT® Software (Version VI).

The ideas we have for improving low-to-medium risk investigations alone are worth buying the new set.

Book 3: Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents, is included in the 2-Day TapRooT® Root Cause Analysis Training. The 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training include Book 4: Using TapRooT® Root Cause Analysis for Major Investigations, and Book 3.

But that’s just two (Books 3 & 4) of the new books. What else is there and what new information is in the other six books? Read on…



Until Book 1: TapRooT® Root Cause Analysis Leadership Lessons was written, we really didn’t have a book that explained the concepts of TapRooT® Root Cause Analysis to management. Now we have produced a concept book that is just 70 pages long (think of it as a bedtime story for management). When management asks what they need to know about TapRooT®, Book 1 is the place to start.

Of course, we would like leaders to learn much more about a tool that should be in their leadership tool kit but Book 1 is a starting point to get management to understand the basis for TapRooT® and how it will help them improve safety, quality, productivity, and environmental compliance.

To learn more about this book, CLICK HERE, or order your copy at:



Book 2: TapRooT® Root Cause Analysis Implementation, is for those in charge of an improvement program. It explains how TapRooT® can be used to improve an already existing program or part of a completely new improvement effort.

Making this a separate book (89 pages long) helps the right people get the right information to make their improvement program much more effective.

What’s in the book?

  • The “Just Do It!” method of getting started.
  • How to add TapRooT® Root Cause analysis to an existing 6 Sigma, Lean, 8-D, Process Safety, Behavior-Based Safety, or other improvement initiative.
  • Building a best-in-class improvement initiative.
  • A checklist to evaluate your improvement efforts.

If you are serious about improvement and in charge of a program to make improvement happen … this book is for you. Order it HERE.

Book 5

This book is close enough to finished that I can explain what you will find in it when it comes out. If you are interested in equipment troubleshooting and root cause analysis, this is the book for you.

Book 5: Using Equifactor® Troubleshooting Tools and TapRooT® Root Cause Analysis to Improve Equipment Reliability, explains how to use TapRooT® and Equifactor® to solve equipment problems. The new book explains the techniques and includes a paper version of the equipment troubleshooting tables from the TapRooT® VI Software all in one book. That makes this a much handier reference.

We expect this book to be available in the 1st half of 2018. Watch our newsletter for more information.


Book 6

Book 6: TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement, explains how to build TapRooT® root cause analysis into your audits and proactive improvement efforts. It’s only 57 pages long and is a great compliment to books 3 and 4.

It describes the 7-step process for using TapRoot® in an audit and how to build TapRooT® techniques into your proactive improvement efforts.

When you order the book HERE, you will also get the latest:

  • TapRooT® Root Cause Tree®
  • TapRooT® Root Cause Tree® Dictionary
  • TapRooT® Corrective Action Helper® Guide

What’ new about book 6? It is the latest information about using TapRooT® to audit performance. It can be used for safety or quality audits. It’s a very fast read.

This book is included in the course materials for the pre-Summit TapRooT® for Audits Course.


Book 7

Book 7: TapRooT® Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills, is all about information collection. We’ve never had a book specifically about this topic. In the past you had to find some of the information provided here buried in the steps of the old 2008 TapRooT® Book.

But this book is more than just a rehash of the information about interviewing and evidence collection. In  addition to information about planning your evidence collection, emergency response and scene management, and the TapRooT® investigation process, it includes:

  • The 3 P’s and an R of evidence collection. (People, Paper, Physical, and Recordings)
  • The TapRooT® 12-Step Interview Process (Cognitive Interviewing)
  • Decoding non verbal behavior
  • Building your investigation kit
  • An initial observation form
  • An interview preparation form
  • An evidence log
  • How to use Change Analysis and CHAP as part of an interview/evidence collection process

That’s a lot to pack into a 93 page book! Buy this book by CLICKING HERE.

Book 8

This book is also still in production but is also expected in the first half of 2018. Book 8: TapRooT® Performance Measures and Trending for Safety, Quality, and Business Management, explains the state-of-the-art in performance measurement and trending.

If you have ever wondered how you can prove that you have improved or if a “negative” trend is actually significant, this is the book for you.

In addition, the book explains what management should know about trends. This information can keep them from being misled by false trends and how to use trends to manage improvement initiative.

The math involved isn’t complicated, but it is beyond some of the common “trending” graphs that you may be using now.

This book is included in the pre-Summit Advanced Trending Techniques Course. Watch our newsletter for more information on when the book will be available.

KEEP UP TO DATE! If you don’t have the latest TapRooT® Books that apply to your work, order them today!

Resolve to Improve!

January 2nd, 2018 by


On New Year’s Eve, did you make a resolution? According to the data company, iQuanti, here were the top seven resolutions made:

  1. Get healthy.
  2. Get organized.
  3. Live life to the fullest.
  4. Learn new hobbies.
  5. Spend less/save more.
  6. Travel.
  7. Read more.

Are you surprised by any of the above? Nothing earth shattering there.  Outside personal improvements, there is a way to truly make a difference in your own life as well as the lives of others. The one resolution not on the top seven list that you shouldn’t overlook is a work-related resolution.

Here are some work-related resolutions to consider…

  • Eliminate the blame environment when someone makes a mistake.
  • Stop problems from happening over and over again.
  • Save time and get better results when you perform an incident investigation.
  • Learn best practices to make your workplace safer and more productive.
  • Become better at your job by applying state-of-the-art root cause analysis.

How do you do these things?


Start by attending TapRooT® Training. See our upcoming courses here:

Then make sure that you are at the 2018 Global TapRooT® Summit to learn best practices from around the world. That’s the best place to learn best practices from industry leaders from around the world. The Summit is in Knoxville, TN, on February 26 – March 2. See the Summit schedule here:

And register here:

The knowledge you will gain will help you make 2018 the best year ever.

Are you interested in improving human performance? Try this four step plan!

December 19th, 2017 by


Is discipline the main way you “fix” human error problems?

Are you frustrated because people make the same kind of mistakes over and over again?

Have you tried “standard” techniques for improving human performance and found that they just don’t get the job done long term (they have an impact short term but not long term)?

Is management grasping for solutions to human error issues?

Would you like to learn best practices from industry human performance experts?

Try this four step plan:


1. Attend a 5-Day TapRooT® Advanced Root Cause Analysis Course.

The TapRoot® System is made to reactively and proactively help you solve human performance issues. It has built in human factors expert systems that guide you to the root causes of human errors and help you develop effective fixes. The 5-Day TapRooT® Course is the best way to learn the system and get started fixing human performance issues.

See the upcoming course schedule here:


2. Attend the Understanding and Stopping Human Error Course

At this two day class, Dr. Joel Haight, a human factors and safety improvement expert and industrial engineering professor at the University of Pittsburg (where he is the Director of the Safety Engineering Program) shares the reasons why people make mistakes and what you can do to understand the problems and fix them.

Joel is an expert TapRooT® User having extensive experience apply TapRooT® to fix human factors problems at a Chevron refinery and in the oil field in Kazakhstan. He is also an expert in applying other human performance analysis and improvement techniques. He brings this knowledge to the 2-Day Understanding and Stopping Human Error Course.

It is best if you have already attended at least a 2-Day TapRooT® Course prior to attending this course. See the course description here:


3. Attend the Human Factors Track at the 2018 Global TapRooT® Summit

Once a year we put together a track at the Global TapRooT® Summit that is designed to share best practices and the latest state-of-the-art techniques to improve human performance. That’s what you get at the Human Factor Track at the Summit. What are the sessions at the 2018 Global TapRooT® Summit?

  • TapRooT® Users Share Best Practices – This is a workshop designed to promote the sharing of investigation, root cause analysis, and human performance best practices from TapRooT® Users from around the world. Every year I attend this session and get new ideas that I share with others to help improve performance. Many say this is the best session at the Summit because they get such great ideas and develop new, helpful contacts from many different industries.
  • Top 5 Reasons for Human Error and How to Stop Them – Mark Paradies, President of System Improvements and a human factors expert, shares his deep knowledge of the top five reasons that he see’s for people making “human errors.” For each of these he shares his best ideas to stop the problems in their tracks.
  • Stop Daily Goofs for Good – Kevin McManus, a TapRooT® Instructor and performance improvement expert, shares systematic improvement ideas s to prevent human error and improve cognitive ergonomics on the job.
  • Using Wearables to Minimize Daily Human Errors – Using “wearables” is a technological approach to error prevention. Find out more about how it is being used and may be applied even more effectively in the future.
  • Alarm Management, Signal Detection Theory, and Decision Making – Are people at your facility overwhelmed by alarms? Do the become complacent because of nuisance alarms? Dr. Joel Haight, Director of the University of Pittsburg Safety Engineering Program will discuss control system decisions, decision execution, alarm management, signal detection theory, and decision making theory and how it could be critical in an emergency situation.
  • The Psychology of Failing Fixes – Why do your fixes fail to prevent human error? That’s what this session is all about!
  • What is a Trend and How Can You Find Trends in the TapRooT® Data? – looking for trends in human error data is an important activity to identify generic human factors problems and take the first step to major human performance improvements. Now for the bad news. Most people really don’t understand trending. Find out what you need to know and how to put trending to work in your improvement program.
  • Performance Improvement Gap Analysis – This is the session where you put everything together. Where does your program have holes? How can you apply what you have learned to fill those holes? What are others doing to solve similar problems? Put your plan together so you are ready to hit the ground running and make improvements happen when you get back to work.

And the Best Practice Sessions outlined above are only a start. You will also see five great Keynote Speakers:


Mike Williams will share his experience surviving the Deepwater Horizon explosion.


Dr. Carol Gunn will share the story of the her sisters unnecessary death in a hospital and patient safety improvement.


Inky Johnson will share his experience with a debilitating football injury and how it changed his life and helps him inspire excellence in others.


Mark Paradies will help you get the most out of your application of TapRooT®.


Vincent Ivan Phipps will teach yo to amplify your leadership skills and communication ability.

We know that the Summit will provide you with new ideas and the inspiration to implement them.


4. Get started! Analyze your human performance issues and make improvements happen!

Just Do It! get back to work and implement what you have learned. Need more help? We can provide training at your site to get more people trained in using TapRooT® so that you have help making change happen.

Don’t wait! Get your four step plan started! Register for the courses and Summit today!

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.

Ten Indicators that your Company may have a Safety Culture Problem

December 11th, 2017 by

What puzzle pieces do you need to put in place to improve your safety culture?

A safety culture is difficult to measure, but there are some indicators that alert us to problems.

  1. There is no visible commitment from leadership.
  2. When there are competing priorities, safety comes in second.
  3. Workers feel uncomfortable reporting safety issues to their supervisors.
  4. Safety is viewed as more of a cost than an investment.
  5. Injuries and illnesses are sometimes swept under the rug.
  6. Safety issues are dealt with in an untimely and inefficient manner.
  7. Workers do not have the power or resources to find and fix problems as they see them.
  8. Managers are never seen on the shop floor with the workers.
  9. Safety is not part of the everyday conversation.
  10. Workers are blamed for accidents.

Do any of these sound familiar? If you identify problems like those listed above, you can improve your facility’s safety culture. We’re excited to welcome Brian A. Tink and Brian W. Tink back to the Global TapRooT® Summit to share their popular 2-day Pre-Summit course, “TapRooT® Analyzing and Fixing Safety Culture Issues.”

Click here to learn more about this course.

Register now for the 2-day course only (Febuary 26 and 27)

Register now for the 3-day Global TapRooT® Summit and this 2-day course (February 26 – March 2)

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?

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…

Can Your Company Afford a Second Rate Improvement Program?

November 28th, 2017 by


Sometimes it seems like management’s only objective is to cut costs. Can you produce excellence and record profits by cost cutting alone? Your company needs a world-class improvement program!

How do you get a world-class improvement program? As George Washington Carver said:


Start where you are with what you have.
Make something of it and never be satisfied.

Have you become satisfied? Is it time to improve?

If you have never attended TapRooT® Training, start your improvement journey with a 2-Day TapRooT® Root Cause Analysis Course.

But most readers here have already learned the basics. They are ready for more. Perhaps a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. It’s a great place to learn to improve your skills to learn to investigate difficult, high-risk incidents.

If you are looking to go beyond just improving your own knowledge and you want to improve your company’s performance improvement initiatives, try reading our new book:

TapRooT® Root Cause Analysis Implementation – Changing the Way Your Company Solves Problems


CLICK HERE to get your copy.

That’s a great start but there is even more…

Would you like to benchmark with industry leaders and learn from improvement experts from around the world? Attend the 2018 Global TapRooT® Summit. Many Summit attendees have explained that attending the Summit is a great way to learn from others and make your improvement program world-class.

People share their success and learn from others…

Many attend the pre-Summit advanced courses to get even more learning packed into their trip…

NewImage(Barb teaching the Effective Interviewing and Evidence Collection Course)

Improvement is a never ending cycle of discovery. What are you doing to move the process forward?


Is it time to make your improvement program world-class or are you settling for second rate performance?


How Do You Get Started Using TapRooT® to Improve Your Root Cause Analysis?

November 21st, 2017 by


Start where you are, with what you have.
Make something of it and never be satisfied.
George Washington Carver

When someone asks me where they should start when implementing TapRooT® to improve root cause analysis, my answer is ALWAYS:

It depends on where you are.

Your company vision makes all the difference in deciding what you need to do first to implement TapRooT® as you problem solving tool of choice.

What is your corporate vision? It is one of these three:

  • Blame Vision
  • Crisis Vision
  • Opportunity to Improve Vision

If you don’t know about these three types of “Vision,” read about them in the TapRooT® Root Cause Analysis Leadership Lessons book.

If your company looks for problems as an opportunity to improve, you are in luck! Your company has the Opportunity to Improve Vision and you have a high probability of success! You can begin with any of the “getting started” sections of the book, TapRooT® Root Cause Analysis Implemention – Changing the Way Your Company Solves Problems.

There are three main places to start that are described in the book…

Chapter 1 describes the most frequently used way to start using the TapRooT® Root Cause Analysis System: “Just Do It.” This is a fast way to see the benefits that TapRooT® Root Cause Analysis provides.

Chapter 2 describes incorporating the TapRooT® Root Cause Analysis Tools into an already existing improvement system. If you have implemented Lean, Six Sigma, TQM, RCM, TPM, ISO, Operational Excellence, Process Safety Management, Patient Safety, Behavior Based Safety, or HU, this might be the place that you choose to start implementing TapRooT®.

Chapter 3 describes a complete implementation of TapRooT® based on the best practices we have observed from TapRooT® Users from around the world. This guide to audit a “complete” implementation may seem complex. Perhaps that is why so many TapRooT® Users start with the simpler methods described in Chapters 1 and 2 and use Chapter 3 as their ultimate goal.


Read TapRooT® Root Cause Analysis Implemention – Changing the Way Your Company Solves Problems and learn more about implementing TapRooT® at your site. Or give us a call at 865-539-2139 or contact us through our web site by CLICKING HERE to discuss your options.

But whatever you do … DON”T WAIT. Problems aren’t going to get any smaller while you wait to improve your root cause analysis.

Connect with Us

Filter News

Search News


Angie ComerAngie Comer


Anne RobertsAnne Roberts


Barb CarrBarb Carr

Editorial Director

Chris ValleeChris Vallee

Human Factors

Dan VerlindeDan Verlinde

VP, Software

Dave JanneyDave Janney

Safety & Quality

Garrett BoydGarrett Boyd

Technical Support

Ken ReedKen Reed

VP, Equifactor®

Linda UngerLinda Unger


Mark ParadiesMark Paradies

Creator of TapRooT®

Per OhstromPer Ohstrom

VP, Sales

Shaun BakerShaun Baker

Technical Support

Steve RaycraftSteve Raycraft

Technical Support

Wayne BrownWayne Brown

Technical Support

Success Stories

Reporting of ergonomic illnesses increased by up to 40% in…

Ciba Vision, a Novartis Company

We started using TapRooT® in the mid 1990s after one of our supervisors wanted to instill a more formal process to our investigations…

Contact Us