Category: Root Cause Analysis Tips

Root Cause Analysis Tip: How Are Managers Involved in a Root Cause Analysis?

July 23rd, 2014 by

I’m sure the answer to this question varies from company to company. But I also know that the best root cause analysis programs I’ve seen had the most involved managers.

Here are some suggestions to consider…

FIRST, management should be asking for (demanding) root cause analysis. They should insist on it when something bad happens. And they should make sure that there are sufficient trained investigators available and that they have the time they need to actually investigate the problem. But also, management should insist that root cause analysis be used proactively to stop problems before they happen.

SECOND, management needs to set the standard for what is an acceptable root cause analysis. If management accepts substandard reports, presentations, and corrective actions, it will be no wonder that the program fails. But to set the standard, they must know what can be accomplished and what they should look for when they review the results of a root cause analysis.

THIRD, management needs to be self-critical and encourage investigators to look for Management System problems. See the Root Cause Tree® if you don’t understand what a Management System problem is.

FOURTH, management needs to make sure that investigators go beyond specific root causes and look for generic root causes. This should be part of the questions that management asks for every serious incident review.

FIFTH, management should make a special effort to reward good root cause analysis. I didn’t say perfect root cause analysis. Rewards should be for every good root cause analysis. 

Do these five points give you any ideas?

Root Cause Analysis Tip: Is Human Error a Root Cause?

July 17th, 2014 by

A frequent question that I see in various on-line chat forums is: “Is human error a root cause?” For TapRooT® Users, the answer is obvious. NO! But the amount of discussion that I see and the people who even try suggesting corrective actions for human error with no further analysis is amazing. Therefore, I thought I’d provide those who are NOT TapRooT® Users with some information about how TapRooT® can be used to find and fix the root causes of human error.

First, we define a root cause as:

the absence of a best practice or the failure to apply knowledge that would have prevented a problem.”

But we went beyond this simple definition. We created a tool called the Root Cause Tree® to help investigators go beyond their current knowledge to discover human factors best practices/knowledge to improve human performance and stop/reduce human errors. 

How does the Root Cause Tree® work?

First, if there is a human error, it gets the investigator to ask 15 questions to guide the investigator to the appropriate seven potential Basic Cause Categories to investigate further to find root causes.

The seven Basic Cause Categories are:

  • Procedures, 
  • Training, 
  • Quality Control, 
  • Communications, 
  • Human Engineering, 
  • Work Direction, and 
  • Management Systems.

If a category is indicated by one of the 15 questions, the investigator uses evidence in a process of elimination and selection guided by the questions in the Root Cause Tree® Dictionary.

The investigator uses evidence to work their way down the tree until root causes are discovered under the indicated categories or until that category is eliminated. Here’s the Human Engineering Basic Cause Category with one root cause (Lights NI).

Screen Shot 2014 07 08 at 10 35 20 AM

The process of using the Root Cause Tree® was tested by users in several different industries including a refinery, an oil exploration division of a major oil company, the Nuclear Regulatory Commission, and an airline. In each case, the tests proved that the Tree helped investigators find root causes that they previously would have overlooked and improved the company’s development of more effective corrective actions. You can see examples of the results of performance improvement by using the TapRooT® System by clicking here.

If you would like to learn to use TapRooT® and the Root Cause Tree® to find the real root causes of human error and to improve human performance, I suggest that you attend our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course and bring an incident that you are familiar with to the course to use as a final exercise. 

Note that we stand behind our training with an ironclad guarantee. Attend the course. Go back to work and apply what you have learned. If you and your management don’t agree that you are finding root causes that you previously would have overlooked and that your management doesn’t find that the corrective actions you recommend are much more effective, just return your course materials and software and we will refund the entire course fee. No questions asked. It’s just that simple.

How can we make such a risk-free guarantee?

Because we’ve proven that TapRooT® works over and over again at industries around the world. We have no fear that you will see that TapRooT® improves your analysis of human errors, helps you develop more effective corrective actions, and helps your company achieve the next level better level of performance. 

Root Cause Analysis Tip: 5 Ways to Improve Your Interviews

July 10th, 2014 by

1) Pick a Good Setting

What is a good setting? Someplace quiet where the interviewee can think without being disturbed. No visual or audible distractions. A place where the interviewee is comfortable and not threatened.

What is a bad setting? The plant manager’s office (threatening). The cafeteria at lunch (distracting). Out in the plant with work going on (distracting).

2) Be Prepared

Perform the interviews in the order to collect the facts first and then look into more complex issues (management system and generic causes). Data collection interviews come before management interviews.

Before any interview, make a list of the topics you hope to cover.

And, of course, be prepared to draw a SnapCharT® during the interview.

3) Don’t Ask Questions

People get the idea that interviews are all about asking questions. Actually, interviews should be about collecting information by getting the interviewee to tell you what they know: Explore his or her recollections (memory).

Often, asking questions hurts this process by interrupting the interviewee’s train of thought. Instead of asking questions, try the cognitive interviewing process taught in the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. We teach people how to combine cognitive interviewing techniques that help people remember what happened with the TapRooT® SnapCharT® technique.

4) Review What Was Collected

When the interview is nearly complete, review what you have learned with the interviewee.

An easy way to do this is to build an informal, draft SnapCharT® during the interview and then review it step by step with the interviewee once the interview is complete.

If you tell the interviewee that you will review what you learned from them at the end of the interview, this often helps the interviewee feel at ease. They can correct any mistakes they make later. Also, they can correct any misconceptions you might have had and fill in additional information that you didn’t pick up which they thought they told you about.

5) Remember to Say Thanks

At the end of an interview, it’s always good to thank the interviewees for their hard work.

But the “thank you” can serve an additional purpose. You can provide the interviewee with your business card and tell them if they remember any additional information after the interview, that they should write it down and then give you a call. Tell them that if they miss you when they call, they should leave a message with all the information they wrote down. 

Root Cause Analysis Tips: Ever heard of the Dvorak Keyboard?

July 9th, 2014 by

Have you ever heard of the Dvorak Keyboard?  If not, then you are like most people.

Over the last decade we have helped over 100 customers implement the TapRooT® Web Enterprise Software into their Information Technology networks, and business practices.One thing we’ve learned in that time is that every customer approaches implementation from a different perspective.

Some Companies have their Information Technology department drive the implementation from start to finish; While other Companies have their business users (the Safety people, most commonly) drive the implementation and task the Information Technology with certain objectives.

No matter what the plan of attack is, you need to have a plan (and a champion for that plan) or your implementation will die on the vine, like so many good ideas (including mass adaptation of the Dvorak keyboard) often do.

Below is a document I wrote a few years back to provide to our customers who are undertaking implementation. This document is based on my years of experience implementing software, not just TapRooT®.   What I’m implying is that software implementation has some universal truths that have nothing to do with TapRooT®, they have to do with gaining momentum in implementing a new innovation.

You might even learn a few things about that mysterious Dvorak Keyboard. Click Here To Review this Document.

Root Cause Analysis Tips – Building a Better SnapCharT®

June 25th, 2014 by

Welcome to this week’s root cause tips. This week I would like to talk about the SnapCharT®


As you know, the SnapCharT® is the tool I use to plan my investigation, document my evidence, and present the incident to management. It’s a powerful yet easy tool to help in each of these areas.

First, let’s talk form. One of the common problems I see when people first start developing a SnapCharT® is trying to get too much information in a small space. I normally start the first page with no more than 4-5 events across the top of the page. As you continue to develop your timeline, you will soon know if you need to more pages, but the software also knows and will create the page for you. It is much easier to add your evidence if you leave plenty of room to work. If you try to put 10 events at the top of your page you will soon run out of space for your evidence. Your chart will be cluttered, hard to digest, and impossible to present with. I want to see a lot of evidence, but I want it to be organized and look good. This will make it much easier to read and understand it as I use the information later for my root cause analysis.

I’ve already said there should be a lot of evidence on the chart. Everything you know about the incident should be there. If you have been to a TapRooT® course before, you know that we always do a final exercise, and as part of the exercise the instructor will approve your causal factors. When I do this, sometimes the discussion begins with a student saying “let me tell you what happened” at which point I say STOP! – I should be table to tell what happened by reading your SnapCharT®! As I review it and start to ask questions, answers pour out of the team, but some of that information is not on the chart. Make sure everything is there. That way you will not forget anything when you do your analysis, and you will get fewer questions when presenting. And, make sure everything on the chart is factual.

Next, wording matters. Don’t be vague, be very specific. Don’t say it was hot; say it was 90 degrees. Use job titles or functions instead of names to reduce blame. Be very clear with your wording so someone who knows nothing about the incident can tell from your wording exactly what you mean. Get good at using the words ‘”did not” to describe things that were supposed to happen but did not; this will make causal factor identification much easier later in the process.

I try to assemble all my evidence directly below the event in a straight line so it is very easy to read and is arranged into nice groups of information. It is permissible to have two rows of information if it makes sense to do that, but I find that this is not always needed. When it is, make sure each row of information goes together in a logical group; for example, you might have a group with all the training information and another group with all the policy information. If you have been to a 5 day TapRooT® course, you might remember when we talk about procedures we say “the burden of written communication is on the writer, not the reader.” SnapCharT®s are no different!

Optionally, you might elect to put safeguards on your chart. Resist the temptation to only put failed safeguards. In fact, showing safeguards that worked on your chart for your management presentations is a great way of showing two things; what is working in the business, and that the incident could have been worse.

If you have been to a TapRooT® course, you have heard this before, but it is worth repeating – draw your lines last! If you draw your lines too early and you end up having to move things around, you will end up having to delete them. Don’t work any harder than you need to.

The last thing I want to address is the use of colors. It is fine to use colors if you want, but be careful and use light colors. If you use a dark color, it may look fine on your computer, but when you go to present people may not to be able to read it on the screen. I have seen people show causal factors in a different color in their presentations, and that is a great way to bring that information out. I say that you cannot go wrong with black and white. Then again, I am obsessed with simplicity, and I know not everyone is wired that way. Do what makes sense for you.

So that’s it for this week. I hope some of this information is helpful. Thanks for readying the blog, and happy investigating.

Root Cause Analysis Tips: 2014 Global TapRooT® Summit Best Practices (Chevron Phillips)

June 12th, 2014 by

Kenneth Wilburn of Chevron Phillips shared a great best practice at the 2014 Global TapRooT® Summit. Watch his video below, and learn how Kenneth used TapRooT® to reduce injuries at his facility:

If you’re not able to watch the video right now, below is a transcription of his tip:

“Hello my name is Kenneth Wilburn. I work for Chevron Phillips Chemical Company in Port Arthur, Texas. Through the TapRooT® investigation we conducted as a whole company we realized we were lacking in training our short service worker contractors.

A short term contractor is someone who’s worked less than 6 months in our facilities. In Southeast Texas you have your big Exxonmobils, BASF, Duponts, you have thousands of contract workers. You can’t take for granted that these contract workers and have the same work ethic and same safety aspect at every facility, because some facilities are VPP sites, and some are not. what we did, is we recognized this and we took a proactive approach.

Every contractor at our facilities, if they haven’t been working there for six months, they go through a one-on-one training for an hour before they’re allowed to start working at the facility. Then we hand that training off to the safety representative of the contractor and they continue in this program for 90 days. We’ve seen a large reduction in our reportable injuries because of this.”

Want to learn more about our 2015 TapRooT® Summit in Las Vegas?

Click here:

Root Cause Tip – What Should Managers Know About Root Cause Analysis?

June 4th, 2014 by

Hello and welcome to this week’s root cause tip.

Root Cause Analysis is no different than any other program at your company in that it requires management support. And to get support you must first have understanding.

In a perfect world, managers understand root cause analysis because they have been trained, so the best thing you can do is convince them to attend training. If you are having an onsite TapRooT® course, open it to more people, including managers. Even those who might not actually do investigations should understand the process and how root causes were determined, that way when they see a report later they will understand. A two day TapRooT® course would be fine for managers in that situation.

If you can’t convince them to attend, show them an example of a completed investigation and how you drove the evidence down to root cause and got to corrective actions. If you can show how you solved an important and/or ongoing problem, that will make your case much stronger. Which brings me to another point; sometimes you have to show people that you do have problems that need to be solved, so use your metrics to do that. Incidents, near misses, audit findings, hazard reports, and many other sources of data are available to you to make the case. If people do not see a compelling reason to change, they won’t.

Managers must also understand that blame and discipline is like fixing your problems one person at a time. Until you can show them to how to get to the true root cause level, they might not understand this.

Managers speak the language of money. If they understand just how much money is being saved by improving, they will be your advocates.

Managers should also understand how root cause analysis ties in to the organization’s goals; maybe it is cost reduction or maybe it is a key metric other than money. Show how your efforts make a difference.

This is food for thought but more so a call to action. Tell your managers today how important root cause analysis is, educate them, and enlist their support. You will be glad you did. Thanks for reading this week’s root cause analysis tip, and happy investigating.

Root Cause Analysis Tip: Analyze Things That Go Right … The After-Action Review

April 30th, 2014 by

Some claim that root cause analysis is only a reactive tool … something to use AFTER something bad happens.

A much better idea is to use root cause analysis proactively to stop bad things before they happen.

One way to use root cause analysis proactively is to analyze success.

Even when things don’t go wrong, do a root cause analysis after-action review to find out why things went right. Once you understand what causes success, you can repeat success and avoid failure.

To do an after-action review root cause analysis, start by drawing a SnapCharT® of the real way the job was done. Analyze the risks taken and why things worked. You may be able to find ways to make the process even better or to eliminate risks that weren’t necessary. This might make you even more successful next time.

Also, look for things that made the process work and make sure they aren’t lost. Success is a habit and you need to make sure that good practices aren’t forgotten.

Some of the worst stories of failure I’ve heard were people who thought they were saving time, effort, or money but were actually removing the steps in the process that made success happen. When things later failed, it was because they had “lost” good practices to cost cutting and efficiency efforts.

Once you have a good SnapCharT®, look for the opposite of root causes using the Root Cause Tree®.

What is the opposite of a root cause? First think about this definition of a root cause:

Root Cause

The absence of a best practice or the failure to apply knowledge that would have prevented the problem.
(From The TapRooT® Book Copyright © 2008. Used by Permission.)

The Root Cause Tree® helps you look for missing best practices or missing opportunities to apply knowledge. Therefore, you can use the Root Cause Tree® to spot where you were using good practices and knowledge to avoid (eliminate) Causal Factors. The absence of these Causal Factors helped you be successful (not have an incident).

Once again, we want to reinforce the good practices and make sure they aren’t eliminated by mistake.

For example, if the mechanic used a checklist, reinforce that that was a good practice that should be used again. Don’t let the mechanic get the idea that “now that I’ve done it once successfully, I don’t need a checklist any more.”

One additional technique that can be helpful in recognizing why things went right is Safeguards Analysis.

When we teach Safeguards Analysis, we usually use safety examples because these are the easiest way to understand the concept of a safeguard.

Screen Shot 2014-04-28 at 11.45.18 AM

But the same concept can be applied to quality problems, maintenance issues, or operations excellence. The idea is to look for the safeguards that were in place to keep problems from occurring.

You may find that even if you were successful, you may have had some safeguards fail but an accident, quality problem, maintenance failure, or operating problem didn’t occur because another redundant safeguard worked.

For example, a mechanic working on a pump might have opened the wrong valve and contaminated a batch of chemicals being processed in a nearby unit, but didn’t because he asked an operator to second check what he was about to do. He had made a mistake following a procedure (a failed safeguard) but asking the operator to second check his work (an additional safeguard) kept things from going wrong.

In this case we can reinforce the safeguard that worked (the second checker), but need to do a root cause analysis on the safeguard that failed (maintenance error that was caught by the second check). The root cause analysis portion of this after-action review is just like the root cause analysis of any other incident (SnapCharT® and Root Cause Tree®). The only difference is that the Causal Factor was not allowed to become an incident because another safeguard worked.

One last note. Analyzing things that go right is perhaps the most important part of an improvement program for companies that have excellent performance.

Why? Because when your performance is excellent, there are usually redundant safeguards that keep performance at this high level. Analyzing what goes right allows management to see if one of those redundant safeguards is failing without waiting for additional safeguards to fail (causing a real accident).

Using TapRooT® Root Cause Analysis to analyze why things go right is a best practice that the best should be using!

If you would like to learn more about applying TapRooT® Root Cause analysis either reactively or proactively, consider attending a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. CLICK HERE for more information.


Root Cause Analysis Tip: How to Perform Faster Investigations

April 23rd, 2014 by

magnifyingglassI was looking through some old blog posts and found one that I thought current readers might find especially helpful. This one is a “blast from the past” – 2005 to be exact and discusses ways to perform faster root cause analysis.

Make sure you read the whole post because some of the best ideas are toward the end. See:

For those who have the 2008 (black) TapRooT® Book, see page 40 for a quick rundown on performing fast, simple investigations using TapRooT®.

Root Cause Analysis Tip: TapRooT® is more than a Root Cause Analysis Tool – TapRooT® is Your Performance Improvement Partner!

April 16th, 2014 by

If you are reading this you probably already know about TapRooT® as a root cause analysis system. If you don’t, watch this:


But we want to do more for our clients than helping them fix problems once and for all. We want to help them get a great return on investment from their improvement efforts.

Therefore, we don’t stop by just making TapRooT® the best root cause analysis system that we can invent. We continuously try to find new ideas, new methods, new ways for our clients to be more effective and efficient in their improvement efforts. And we also try to keep them passionate about their improvement efforts so their work can be sustained through the difficulties that people encounter when they try to may positive change occur.

But how do we get this information to the people who need it? Those out their on the factory floor, the oil rig, or even in the corporate boardroom? By several methods.


First, we publish most of what we learn on the Root Cause Analysis Blog.

From these root cause analysis tips, to recent news about accidents, to articles about career development, to course pictures, to Summit information, to TapRooT® software update information, to job openings for TapRooT® users, to our Friday jokes (yes, you can have a sense of humor about improvement), we try to make what we write interesting, short, and to the point so that we communicate things that you may need to know without wasting a bunch of your time.


Because many folks don’t have the time to jump on-line and read the blog every day, we take the information shared on the blog and condense it into a weekly newsletter. We are still experimenting to find the best format for this information to make it readable (or maybe “scannable” is a better word) so that you can pick out what is important to you and learn quickly. 

I know that everyone is busy but I think improvement information is important so that I hope you take the few minutes required to skim the weekly e-mail to see if there is anything important that you need to read and, if you can’t get to it right then, that you print it out for your professional reading stack.


The main way we get the bulk of the details about new improvement ideas out to TapRooT® Users is the annual Global TapRooT® Summit. If you were at the 2014 Summit, you know the value of the best practice sharing and advanced improvement knowledge that goes on at the Summit. You also know that we have excellent keynote speakers to pass along great information and keep you motivated to make improvement happen. To find out more about the Summit, see the Summit web site:

We like to think of ourselves as you performance improvement partners. And now you know how we try to get the latest information to you to help you develop the most effective performance improvement program possible.  

Root Cause Analysis Tip: Targeting Investigations

April 2nd, 2014 by




A client complained, “I just can’t get everything investigated using TapRooT®.” I asked, “What are you investigating?”

The answer?


They were investigating lost-time injuries, medical treatment cases, reportables, near-misses, equipment failures, quality issues, issues management was interested in, the list went on and on …

Don’t get me wrong, I think you can learn valuable information from investigations of small problems. But you have to have a limit. They needed to target their investigations on their highest priority improvements. They need to answer the question: “What are the most important things to improve?”

For example, if your objective is to prevent fatalities, you certainly would investigate fatalities. But you would also investigate incidents with the potential for fatalities. They could be medical treatment cases, near misses, equipment failures, or even serious rule violations. But you would NOT investigate problems that could not produce a fatality … even if it might be a lost-day or medical treatment case. That’s focus!

When resources are scarce, you must focus on your most important improvement opportunities. Once fatalities have been eliminated you can target your efforts on the next issue.

This focus helps you manage your improvement initiative to fit your resources. What if you don’t have enough resources for your most important improvement initiative? Then you have justification to ask for additional resources for the high priority objective.

Don’t be overwhelmed. There are only 24 hours in a day. Target your investigations.


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:

Root Cause Analysis Tip: Performance Tells You If Your Root Cause Analysis is Adequate

March 18th, 2014 by

At a meeting people were benchmarking their root cause analysis efforts. Several declared their root cause analysis systems adequate because they “thought” the reports found root causes. 

That got me thinking? “How did they know?”

They hadn’t performed a separate investigation. They only reviewed what was presented. And most of the time the people were reviewing the results of a 5-Why investigation (notoriously inconsistent).

So I asked myself how I would judge the adequacy of a root cause analysis. My answer seemed simple: RESULTS! If a company’s root cause analysis efforts are adequate, they won’t have repeat fatalities. They won’t have repeat near-misses of fatalities or serious injuries. They won’t have repeat quality issues. They won’t have to perform corrective maintenance for the same serious mechanical failure. If they are a hospital, they won’t have repeat sentinel events or near-misses of sentinel events.

If they have adequate root cause analysis, problems will be solved once and for all. If they have repeat problems, there is something wrong with their root cause analysis and/or corrective actions.

And since most incidents are repeat incidents at most facilities, the investigation is not only missing the root cause of the incident, but also, the root cause of why previous incidents failed to solve the problem.

But here’s the real answer … We all probably need to improve our root cause analysis and corrective action systems!

Even if we get good (adequate) results, we may be able to get BETTER RESULTS MORE EFFICIENTLY.

Where can you get ideas to improve your root cause analysis system and your corrective action program? At the 2014 Global TapRooT® Summit coming up on April 7-11. Don’t miss this chance to make your root cause analysis system produce results that are even better than adequate. See:

News & Current Events: In the Wake of Fukushima, The Natural Resources Defense Council’s Newest Report Condemns the NRC’s Hydrogen Generation Safety

March 12th, 2014 by


From the Natural Resources Defense Council’s Report Preventing Hydrogen Explosions In Severe Nuclear Accidents: Unresolved Safety Issues Involving Hydrogen Generation And Mitigation

“The Nuclear Regulatory Commission is failing to meet the statutory standard of “adequate protection” of the public against the hazard of hydrogen explosions in a severe reactor accident.

After Fukushima Daiichi’s three devastating hydrogen explosions, the NRC decided to relegate investigating severe accident hydrogen safety issues to the lowest-priority and least proactive stage of its post–Fukushima Daiichi accident response.

NRDC believes that the NRC should reconsider its approach and promptly address severe accident safety issues involving hydrogen.”

Click this link to read the full report:

A short synopsis of the findings:

NRDC Report: U.S. Nuclear Safety Regulators Ignore Severe Accident Hydrogen Explosion Risks Despite Fukushima Tragedy

An in-depth interpretation of the findings:

US Nuclear Safety Regulators Continue to Ignore Lessons of Fukushima for Severe Accident Hydrogen Explosion Risk at US Reactors

What do you think? Share your opinion in the comments.

Fukushima Photo courtesy of:

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.

Root Cause Analysis Tip: Six Ways to Improve Root Cause Analysis/Incident Investigation Efficiency

December 5th, 2013 by


Have you read your 2008 TapRooT® Book from cover to cover? If you do, you will find there are many topics that can help you improve investigation efficiency. Appendix C specifically calls out these six:

1) A well thought out strategy

2) The use of technology

3) Management understanding

4) Preparation

5) Help from people in the field

6) Proper use of a SnapCharT®

Each of these is explained in detail in pages 466 – 471 of the book. If you are interested, crack open your book and get reading! You’ll find there is lots more to learn and use!

If you don’t already have your own copy, get some ideas about what’s in the TapRooT® Book by reviewing the table of contents at:

Order the TapRooT® Book at:

But don’t procrastinate! There’s important information in the book that can help you save lives, time, and money.

Root Cause Analysis Tip: Why Do Root Cause Analysis?

November 14th, 2013 by

© Copyright 2013 By System Improvements Inc. Used by Permission.



Have you thought about why you do root cause analysis? What is your purpose? I ask because many people go through the motions of root cause analysis without asking this essential question.

For most people, the purpose of root cause analysis is to learn to stop major accidents by finding the root causes of accidents and fixing them. Obviously, we must analyze the root causes of fatalities and serious injuries. But waiting for a serious accident to prevent a fatality or serious injury is like shutting the barn door after the cow has escaped.

Instead of waiting for a major accident, we need to learn from smaller incidents that warn us about a big accident just around the corner. Thus, root cause analysis of these significant warning events is a great idea.

The same philosophy applies to other types of adverse events that you want to prevent. Quality issues, equipment failures, production upsets, or environmental releases. You want to use root cause analysis to learn from the minor events to prevent the major ones.

This seems obvious. But why do so many companies seem to wait to learn from major accidents? And why do so many others waste tremendous time and money investigating incidents that don’t have the potential to cause a serious loss? Read on for ideas…


Many companies seem to wait for big accidents before they decide to make serious change to the way they manage safety. They think they are doing everything needed to be safe. They may even have evidence (like decreasing lost time injury/medical treatment rates) that they are improving. But, when a major accident happens, the investigation reveals multiple opportunities that were missed before the major accident to have learned from minor incidents. That makes me wonder … Why aren’t they learning?

I’ve seen eight reasons why major companies to fail to learn. These reasons can occur separately or rolled up together as a “culture issue.” They include:


Near-Misses Not Reported

If you don’t find out about small problems, you will wait until big problems happen to react. Often people don’t report near-misses because they are unofficially discouraged to do so. This can include being punished for self-reporting a mistake or being assigned to fix a problem when it is reported. Even the failure to act when a problem is reported can be seen as demotivating.

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Hazards Not Recognized

Another reason that near-misses/hazards are not reported (and therefore not learned from) is that they aren’t even recognized as a reportable problem. I remember an operator explaining that he didn’t see an overflow of a diesel fuel tank as a near-miss, rather, he saw it as a “big mess.” No report means that no one learned until the diesel caught fire after a subsequent spill (a big accident).

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Shortcuts Become a Way of Life (standards not enforced)

This is sometimes called the “normalization of deviation.” If shortcuts (breaking the rules) become normal, people won’t see shortcuts as reportable near-misses. Thus, the bad habits continue until a big accident occurs.

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Process Safety Not Understood

We’ve built a whole course around this cause of big accidents (The 2-Day Best Practices for Reducing Serious Injuries & Fatalities Using TapRooT® Course). When management doesn’t understand the keys to process safety, they reward the wrong management behavior only to suffer the consequences later.


Ineffective Root Cause Analysis

If a problem is reported but is inadequately analyzed, odds are that the corrective actions won’t stop the problem’s recurrence. This leaves the door open to future big accidents.


Inadequate Corrective Actions

I’ve seen it before … Good root cause analysis and poor corrective action. That’s why we wrote the Corrective Action Helper® module for the TapRooT® Software. Do you use it?

Corrective Actions Not Implemented

Yes. People do propose good corrective actions only to see them languish – never to be implemented. And the incidents continue to repeat until a big accident happens.

Trends Not Identified

If you aren’t solving problems, the evidence should be in the incident statistics. But you will only see it if you use advanced trending tools. We teach these once a year at the pre-Summit 2-Day Advanced Trending Techniques Course.

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Another problem that I’ve seen is companies overreacting. Instead of ignoring problems (waiting for the big accident), they become hyperactive. They try to prevent even minor incidents that never could become fatalities or serious injuries. I call this the “Investigating Paper Cuts” syndrome.

Why is overreacting bad? Because you waste resources trying to prevent problems that aren’t worth preventing. This usually leads to a backlog of corrective actions, many of which have very little return on investment potential. Plus you risk losing the few critical improve-ments that are worthwhile in “the sea of backlog.” Thus, an improvement program that isn’t properly focused can be a problem.


You need to truly understand the risks presented by your facility and focus your safety program on the industrial and process safety efforts that could prevent fatalities and serious injuries. Don’t overlook problems or make the mistake of trying to prevent every minor issue. Focus proactively on your major risks and reactively on incidents that could have become major accidents. Leave the rest to trending.


An ounce of prevention is worth a pound of cure.”
Benjamin Franklin

Monday Accident & Lessons Learned: Mining Equipment Accidents

November 11th, 2013 by

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What were the safeguards that were in place and failed that allowed this accident to happen?

Leave your ideas as comments.

Note that failed safeguards are usually causal factors on your SnapCharT®.

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Could you have fixed the broken safeguards or added additional safeguards before this accident happened?

Carl Dixon Shares Life Lessons at the Global TapRooT® Summit – Part 5

November 7th, 2013 by

Carl Dixon, Canadian rock star of The Guess Who, spoke at our 2013 Global TapRooT® Summit. After his devastating car accident, he learned some inspiring life lessons and shared them with us.

In Part 5, Carl shares the mantra he learned during his recovery: “No fear, no weakness.” He learned many more life lessons, and shares one last song with us in this final installment of Carl Dixon’s inspiring story.

Click here to view Part 1.

Click here to view Part 2.

Click here to view Part 3.

Click here to view Part 4.

Carl Dixon will be speaking at our 2014 Global TapRooT® Summit as well! Learn more about our Summit by clicking here.

Root Cause Analysis Tip: How Can You Get Help With a Difficult Investigation?

October 31st, 2013 by

What do you do when you are faced with a difficult investigation (root cause analysis)?

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The first place to start is your TapRooT® Book!

Review Chapter 4. You will find information that will help you with difficult investigations.

After that, what’s next?

If your company has a world-class implementation of TapRooT®, you will have investigation coaches that can help you with difficult investigations. These coaches have attended the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training, have experience with difficult investigations, and probably have attended several of the Global TapRooT® Summits.

What if your company doesn’t have coaches or they aren’t available?

Call us! call 865-539-2139 and ask to speak to one of our TapRooT® Instructors. They may be able to coach you over the phone.

If more extensive help is needed, they can help you get a facilitation agreement in place an provide an on-site facilitator from our many experienced instructors.

Don’t stumble along with questions unanswered. Start with the book and work your way down the list to find help when you need it!

Carl Dixon Shares Life Lessons at the Global TapRooT® Summit – Part 4

October 31st, 2013 by

Carl Dixon, Canadian rock star of The Guess Who, spoke at our 2013 Global TapRooT® Summit. After his devastating car accident, he learned some inspiring life lessons and shared them with us.

In Part 4, Carl shares about his painful time in the hospital and seeing his wife jump into action to do everything she could for him to recover from his accident. Make sure you watch until the minute 3:00 – he sings a powerful song about this time in his life.

We’ll share his talk with you in a series of installments over the next couple of weeks.
Come back next week for Part 5!

Click here to view Part 1.

Click here to view Part 2.

Click here to view Part 3.

Carl Dixon will be speaking at our 2014 Global TapRooT® Summit as well! Learn more about our Summit by clicking here.

Root Cause Analysis Tip: What’s The Incident – What’s the Causal Factor?

October 24th, 2013 by

CLICK HERE for an article about a fish kill near Honolulu.

It seems that there was a 1,400 ton leak from a molasses pipeline from loading molasses tankers.

The sugary “pollutant” killed thousands of fish.

The dead fish, now being cleaned up by the Hawaii Department of Health, attract sharks, eels, and barracuda (the natural cleanup crew).

Because of the increased risk in shark attacks to surfers, swimmers, and snorkelers, beaches have been posted with an advisory to stay out of the water.

So, up to this point, what is the incident? (The incident in the statement in your circle on your SanpCharT®.)

Leave your answer as a comment here.

But next, if someone ignored the warnings, and entered the water, and was bitten by a shark, would that change the incident? Or would it be a completely separate incident?

Leave your answer in the comments.

Finally, can you already see any causal factors that you should explore as an investigator?

Leave your answer here in the comments.

By the way, is this video a potential corrective action?

Carl Dixon Shares Life Lessons at the Global TapRooT® Summit – Part 3

October 24th, 2013 by

Carl Dixon, Canadian rock star of The Guess Who, spoke at our 2013 Global TapRooT® Summit. After his devastating car accident, he learned some inspiring life lessons and shared them with us.

In Part 3, we learn how Carl Dixon became a part of The Guess Who & April Wine.

We’ll share his talk with you in a series of installments over the next couple of weeks.
Come back next week for Part 4!

Click here to view Part 1.

Click here to view Part 2.

Carl Dixon will be speaking at our 2014 Global TapRooT® Summit as well! Learn more about our Summit by clicking here.

Root Cause Analysis & Career Development Tip: How to Improve Investigation Efficiency

October 17th, 2013 by

It’s frustrating to invest months completing a major investigation only to have it sent back to you for modification because management did not agree on the purpose and scope of the investigation. There is a way to avoid this that takes a little time upfront, but it’s well worth it when all of your efforts are appreciated and approved in the end.

Here are two important tips that will help avoid misunderstanding with management:

1. On major investigations, the investigator (or team) should provide management with frequent updates to keep them in the loop of the progress and potential findings.

2. If the team intends to make recommendations for corrective actions, they should be reviewed in advance with key managers whose departments will be affected. (For example, if a department will have to change the way they do something, or have to supply resources to implement the corrective actions, include them in the loop.)

Management understanding is just one of the tips highlighted in the 2008 TapRooT® Book. If you received a book in TapRooT® Training and skipped over Appendix C, you missed some other ideas that will make your job easier. If you don’t have a book you can learn more about what’s in it here:

Doing an investigation once with everyone on the same page saves time — a little extra effort toward management understanding can help you attain your goal and take a step forward in your career development.

Carl Dixon Shares Life Lessons at the Global TapRooT® Summit – Part 2

October 17th, 2013 by

Carl Dixon, Canadian rock star of The Guess Who, spoke at our 2013 Global TapRooT® Summit. After his devastating car accident, he learned some inspiring life lessons and shared them with us. One of the best pieces of wisdom he shares in Part 2 is “The lessons you learn the hard way last the longest.” Learn the story behind Carl Dixon’s wise words by watching the video below!

We’ll share his talk with you in a series of installments over the next couple of weeks. Come back next week for Part 3!

Click here to view Part 1.

Carl Dixon will be speaking at our 2014 Global TapRooT® Summit as well! Learn more about our Summit by clicking here.

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