Taproot

When healthcare professionals perform root cause analysis (RCA), they want to define “What” happened, “Why” it happened, and then how to “Fix” the problem. These three pieces are considered core pieces to a “Thorough and Credible” RCA as coined and defined by the TJC. The TapRooT® process meets and, quite honestly, exceeds these requirements in many ways. Today, I want to spend a little bit of time focusing on one of the ancillary questions raised on TJC’s matrix that deals with Document Searches.

The key to responding to findings with solid corrective actions is understanding the root cause from every angle. It requires an open mind, creativity and tools to aid the investigator in understanding how to fix both Human Performance and Equipment related issues. Within the TapRooT® process, we have what is called Corrective Action Helper®. This tool provides guidance for identifying “Generic” issues, provides ideas for fixing the Root Causes, as well as providing a ready-made list of References for each root cause. The list of references provides both general industry and healthcare related documents that the investigator should consider reading or referencing as part of the fix. This provides the investigator with documents to review and to answer the question, “Cite any books or journal articles that were considered in developing this analysis and action plan:” from page 5 of the matrix.

Here is an example of what is included in the Documents section in Corrective Action Helper® for just one of our root causes, “Arrangement/Placement.” (This has to do with the physical location of equipment, displays, and controls):

References:

* ANSI/HFES 100-2007, Human Factors Engineering of Computer Workstations, (2007), published by The Human Factors Society.

* KODAK’s Ergonomic Design for People at Work, (2004) by Eastman Kodak Company, published by John Wiley & Sons, Hoboken, NJ.

* Handbook of Human Factors and Ergonomics, Third edition (2006), by G. Salvendy, ISBN 0-471-44917-2, published by John Wiley & Sons, New York.

* Industrial Ergonomics: A Practitioner’s Guide, (1985) by D. C. Alexander and B. M. Pulat, published by Industrial Engineering & Management Press, Atlanta, GA.

* Handbook of Human Factors and Ergonomics in Health Care and Patient Safety, (2007) by Pascale Carayon, published by Eribaum, Mahwah, NJ.

* International Encyclopedia of Ergonomics and Human Factors, Second edition (2006), edited by Waldemar Karwowski, 3 volume set. ISBN 978-0415304306.

* Medical Error and Patient Safety: Human Factors in Medicine, (2007) by George and Barbara Peters, published by CRC.

* Medical Device and Equipment Design: Usability Engineering and Ergonomics, (1995) by Michael E. Wiklund, published by CRC.

With this kind of reference list directly available through our system, why would you use anything else to find root causes? Not only can you provide a thorough and credible RCA, you also have a ready-made list of documents and references for review.

In our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course and in our TapRooT® book, TapRooT® Changing the Way the World Solves Problems, we introduce the Critical Human Action Profile (CHAP) tool to help collect more information to analyze any type of problem at the process task level.  I like to call this looking at a problem at the 1 foot level as opposed to many investigations that analyze their problems at the 100,000 mile view only.

The tip here, however, is “why wait for a problem to use CHAP?”

Identify, Evaluate and Improve before it is too late!

Using a very over simplified list of procedure steps on How to Remove a Fuel Pump, found on the internet, I would like to show you how to use CHAP proactively to improve Safety and Quality during a task.

WARNING: The steps listed in the demonstration example below on removing a fuel pump shall not be used. They are incomplete and not necessarily accurate.

Where to start? First off you already perform  JHA, AHA, JSA, Observations…. So Going Out and Looking (GOAL) should not be new or require a lot more additional resources. The difference is that you will be utilizing your resources more efficiently.

1. Start by identifying a task performed by employees that are critical to:

a. Customer/client satisfaction

b. Product Quality

c. Project Timeliness

d. Employee Safety

e. Customer Safety

f. Environmental Exposure

2. Once the task is identified, list the steps to be performed like listed in the image below.
Note: Do not forget to use the Basic Cause Category Procedure in our TapRooT® Root Cause Tree to look for missing best practices as well when listing the steps.

3. Identify each step of the task that is critical to the items listed in step 1 criteria of this article.
Which steps listed above for the fuel pump removal do you think would be listed as critical?

4. For each critical step in the task perform a CHAP Profile.

Note: For each of the items listed below, do not forget to include the Best Practices listed under the Human Engineering Basic Cause Category in our TapRooT® Root Cause Tree.

Last year, a Delta employee lost his leg when it was crushed by the wheel on a jetway in Knoxville, Tennessee.

I had a little extra time waiting for my flight to Atlanta from Knoxville last Friday so I asked the gate agent about the accident and what had been done to prevent a repeat. She said they were now required to have a spotter to make sure that no one got near the wheels while the jetway was moving (the wheels aren’t visible from the jetway controls).

That’s a Human Action Safeguard.

She also said that no one is allowed to use the stairs or get near the wheels while the jetway is in motion. That was already true when the accident happened but it was re-emphasized to everyone after the accident.

That’s a rule “quasi-Safeguard” that requires human action (compliance) to work.

Thus, a near-fatal accident had two human action related Safeguards that are meant to prevent recurrence of the accident.

Here is a graphic from our root cause analysis training…

Now let’s evaluate the corrective actions used to prevent a possible future fatality using the graphic above…

First, we made a rule that required a spotter during moving of the jetway. This is a human action related Safeguard implemented through a rule. That is the second weakest type of corrective action (#5).

Reemphasizing a rule that previously failed (the second corrective action used) is a training related human performance Safeguard and is the weakest corrective action to prevent recurrence of the accident (#6).

What do you think? If you had a serious accident (lost leg due to crushing) and it had the potential to be fatal, would two weak corrective actions be enough?

Maybe we should start at the top of the hierarchy in the figure above and see what is the strongest reasonable Safeguard that we can employ is…

1. REMOVE THE HAZARD

The Hazard in this case is the jetway weight and moving pinch point when the jetway is in motion. This is difficult to remove. (At least I can’t think of a way to do it.)

2. REMOVE THE TARGET

With current aviation operations, people are required to direct the plane while parking, unload baggage, refuel the plane, etc. Perhaps someday this will be done robotically, but for now, removing people from the jetway environment seems unlikely.

3. GUARD THE TARGET

This one is possible. See this photo below from Frankfurt …

They have implemented a guard to keep people away from the wheels.

Is it 100% perfect? No. People can go around the guard (jump over it?).

Is it better than warning people to be careful?

Yes!

So I sent the photo above to the Knoxville airport management. We’ll see if there are changes in the future to implement a stronger Safeguard to the potentially fatal Hazard.

ARE WE DONE?

NO!

This corrective action (if implemented in Knoxville) only fixes one small set of Hazards – jetway pinch-points in Knoxville. This Hazard exists at airports around the world.

For corrective actions to the Generic Root Cause, Delta would need to get airports around the world to guard the Hazard.

Next time you board a plane at your local airport, see what kind of Safeguard is in place. If you don’t see any, send the airport management (you can usually find a “contact us” link at the airport’s web site) a link to this posting.

ONE MORE THING TO LEARN

How do you develop corrective actions? Do you start at the top of the Safeguard hierarchy and work your way down or do you start at the bottom and work your way up?

Your investigators should have their corrective actions evaluated to see how effective they will be. For potentially fatal accidents, I would recommend using the top three strongest on the list and sometimes allow the fourth if somehow the top three aren’t possible.

The bottom two can be allowed in combination with the top 4, but I would never allow them to be the only corrective action if a fatality was possible.

Stop taking the easy way out. Learn a lesson from this accident (and the corrective actions). Improve your corrective action process by using the strongest possible corrective actions.

Watch the chimpanzee vs. human child in a learning experiment.

Here is the video link: http://youtu.be/nHuagL7x5Wc

We are all trained, or learn, by trial and error on how to use equipment or how to use it “properly”. What happens when you get a better “understanding” of how the equipment works? Here are some of the choices that we could make:

1. Ignore the previous training and just get the prize (work done faster, like the chimpanzee)

2. Continue the rules that you learned or were trained to do (at least in front of the bosses like the children).

3. Stop and ask what’s up?

4. Stop using the tool all together and do not tell anyone.

Often the previous training and experience overrides the new operation steps needed … ever been totally frustrated every time someone changes your computer’s Microsoft Windows version? And no, training by itself does not override experience, practice and repetition does!

I had a discussion not too long ago that OSHA forklift training requirements were met when people were retrained after changing forklifts. Unfortunately, the controls worked exactly opposite on the new forklift and the quick review did nothing to override the past knowledge and muscle motor memory.

Just something to think about when you think “Great Human Factors.”

It is almost here – the 2012 Global TapRooT® Summit.

As you have probably heard, on the two days before the summit we have special pre-summit courses we only teach publicly at the summit (we can do any of them onsite).  The course I teach is called the Advanced TapRooT® techniques course.  In this course, we cover best practices for each of the steps of our seven-step process.  A big focus of the course is identifying causal factors, and I will give you some insight into some of that in the root cause tips on February 15.  Today I wanted to talk about something from the course that is extremely important.  Take a look at this analogy:   

Have you ever wondered why sometimes you do an investigation, things get better, but there are still some of the same problems present – maybe they are not as frequent or serious, but they still occur.  Why is that?  A great deal of the time, I would say because you found some of the causal factors and their root causes, but you may have missed one.  In order to make sure problems do not reoccur, you have to find ALL of the causal factors, and therefore, all of the root causes.  And it all starts with a good SnapCharT®.  You see, it is much easier to find the causal factors if your chart is very clear, is not missing important details, and is well worded.  Most of the time you spend in your investigation should be on this front end of the process – the investment in collecting good information and assembling it on your chart will make finding the causal factors easier, and taking them through the Root Cause Tree® faster.

Hopefully this discussion helps.  If you want to hear more, consider joining us in Las Vegas for the course.  And stay for the summit.

Thanks for visiting the blog and happy investigating.

I wrote this paper for the for the BARQA Journal and they are nice enough to let me republish it here. Click on the pdf below to see the whole article.

The article is written for people interested in root cause analysis to improve pharmaceutical quality, but the problems discussed are common to all industries and apply to those looking to improve safety, operation, maintenance, process safety, and quality.

Sources of Root Cause Analysis Failures by Mark Paradies is published by:

Quasar (Members Magazine of BARQA, British Association of Research Quality Assurance) No. 118 Pages 7 – 10, Jan 2012.

Used by Permission.

In 1963 William Haddon wrote “A Note Concerning Accident Theory & Re­search with Special Reference to Motor Vehicles” in the Annual of The New York Academy of Sciences. This marked the start of “energy transfer” theory.

What did Haddon’s work lead to? The development (by the System Safety Development Center at EG&G in Idaho) of a new analysis technique: Barrier Analysis. Next, Linda Unger and Mark Paradies modified Barrier Analysis to develop the TapRooT® technique Safeguards Analysis. This develop­ment history is interesting but what can we learn from this history that is useful for current investigations?

First, the origin of Safeguards Analysis from motor vehicle accident research may be why Safeguards Analysis is so effective for traffic accident investiga­tion. Safeguards Analysis does a great job showing how few safeguards are in place to prevent traffic accidents. One often finds that the “goodness” of the driver (their alertness, competence, and/or judgment) was all that stood between an accident and no accident.

Second, Safeguards Analysis shows the relationship between administrative control safeguards and human actions. Administrative controls (laws, traffic controls, …) require human action to make them work. For example, a red light doesn’t stop a car. The red light lets drivers know that THEY are required to stop. The driver must take action to comply with the light’s instructions (and avoid an accident). So the safeguard is a combination of an administrative con­trol and human action.

Finally, Safeguards Analysis may show that instead of concentrating efforts on improving the driver, one may want to act to add additional safeguards to keep the hazard away from the target. In high hazard or high accident locations, this may mean modifying roads to add new, innovative safeguards that will prevent collisions instead of providing more driver training or adding new features to cars to reduce injuries after an accident occurs.

In our 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course, we introduce you to the Basic Cause Category “Procedures.” In our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training,  we teach how to write a good procedure. The question is, “how many of you have used the best practices listed under Procedures to write training lessons, policies ……?”

Knowing that policies guide what “how to’s” and “do what’s” need to be created, trained and used, why do they have to be so convoluted and difficult to read? Not to pick on lawyers, but have ever tried to understand a legal document? Aren’t legal documents supposed to keep you out of trouble and not get you in trouble?

Interestingly enough, we even pass policies on policies found in this article.

“On October 13, 2010, President Obama signed into law the “United States Plain Writing Act of 2010.” Thirteen years after President Clinton issued his own “Plain Writing in Government” memorandum, the revised set of guidelines states that by July of this year all government agencies must simplify the often perplexing bureaucratic jargon used in documents produced for the American public. Gone are the grammatically longwinded sentences, replaced with simpler English words, grammar and syntax”

Take this excerpt from a policy; what missing best practices can you identify from the TapRooT® Root Cause Tree?

“The amount of expenses reimbursed to a claimant under this subpart shall be reduced by any amount that the claimant receives from a collateral source in connection with the same act of international terrorism. In cases in which a claimant receives reimbursement under this subpart for expenses that also will or may be reimbursed from another source, the claimant shall subrogate the United States to the claim for payment from the collateral source up to the amount for which the claimant was reimbursed under this subpart.”

Using the Basic Cause Category “Procedures,” I look forward to your missing best practices in the comments section.

Whether doing it by hand or in our TapRooT® Software, what can go into the Rectangles that we call Events (Who did whats or what did whats that occurred during the timeline that you are investigating)?

Whos:

Actions by the Operator, Mechanic, Manager, Vendor, Supplier, Contractor, Technician, Customer Service Rep, Engineer, Designer, Nurse, Doctor … as you can see the list is unlimited but understanding the who (we use job titles only) helps us to see if the who was setup for success prior or during the action he/she performed.

Whats:

Caution ( … this may not be what you expected or have been doing)

Equipment Actions: Relay opened when energized, Butterfly valve stuck shut, I.V. bag port become blocked with debris, fuel gravity fed into container through piping …

Hint: If working with equipment, pull up the equipment and system functional diagram up immediately to help you map out the Events.

Chemical Process Actions: Catalysts heated up, hot mix heated up …

Transactional Process: Purchased order received by customer service, SAP sent late warning to warranty …

Hint: Yes, you can follow a piece a paper, hazardous material shipment.. that is handed off from person to person just like you would a person.

Hopefully, this should open up your investigation options even more! By the way, I even mapped out the actions of a horse and a monkey which was analayzed under Human Engineering.

Read a disturbing article from The Washington Post entitled, “The Pain of Wrong Site Surgery,” and it truly made me pause.

Seven years have passed since TJC provided a “universal protocol” outlining changes in pre-surgery routine. These included surgical site verification, and what was termed a “timeout” prior to any surgery. Based on data collected through self-reported events (not the most reliable data due to inconsistent reporting), and state provided information, there are still wrong site surgeries occurring at an estimated rate of 40 per week in the US. That is a staggering number, approximately 2,100 per year.

The article referenced Peter Pronovost, the Medical Director of the John Hopkins Center for Innovation in Quality Patient Care, stating that studies of wrong-site errors have consistently revealed a failure by physicians to participate in a timeout. This lack of participation is ritualized compliance or doctor’s lip service to the rules. That statement while true shows that even with the new protocols in place, there was little or no change in performance.

Comparing the TJC actions with the statements from Mr. Pronovost, it is clear to me that these actions are being implemented without an understanding of the Root Causes. These are all policy-based initiatives that in the end are dependent upon people following and adhering to policies and procedures.  This shows that if we do not analyze situations and find root causes, we will simply implement weak safeguards that do not fix the issue or change behavior.

From the TapRooT® perspective, let’s evaluate the “universal protocol” implemented in 2004:

1)   Verification of preoperative details – Quasi-Safeguard … admin control dependent on a human action.

2)   Marking of the surgical site – Quasi-Safeguard … admin control or “label” if you will, dependent on a human action.

3)   Timeout prior to procedure – Quasi-Safeguard … admin control or policy dependent on a human action.

All of these placed into current surgical systems and simply placed “over” the current processes have simply not worked.  You are now seeing, based on the statements from Mr. Pronovost and the alarming numbers of wrong site surgeries still occurring, that we have a “SPAC Not Used.”  This based on the current medical culture makes sense if people working in the process feel they are above the rules.

If TJC had performed a more thorough analysis of the actual causes, you might find that there are many other possible causes to these issues:

1)   Enforcement NI – if the attitude that “I am above this” or “I should not have to do this” has become an ACCEPTED practice amongst healthcare providers.  Thus, allowing the culture to grow without or with little consequence except to the patient.

2)   Accountability NI – if it is believed that others are responsible for detecting these errors or are responsible for ensuring proper performance.

And there are likely others. I am not stating that I have those answers. I have not gathered the data or analyzed it. But I can tell you that without a more thorough analysis these problems will continue to happen. Simply applying Quasi-safeguards as listed in the 2004 protocol, without any additional measures to identify or address the actual root causes means you are addressing the Causal Factor without actually knowing the causes. These weak fixes that read well, are not based on actual root causes and, as they are showing, are not having a lasting affect on performance.

When similar events continue to occur (average of 40 per week), and we continue to try the same things over and over again, isn’t that the definition of insanity? And should it not also point out that the corrective actions and measures taken have not worked, were not effective, and we need to revisit not only the fixes, but the analysis as well? Food for thought …

One of the highest rated sessions at the TapRooT® Summit is the “TapRooT® Users Share Root Cause Best Practices” session. Here’s a video of one TapRooT® User sharing an idea …

This idea may or may not apply to your investigations. But just one or two good ideas can “pay for” you Summit attendance by the benefits they create back at work. I had an attendee at the 2010 Summit tell me that one idea he learned was going to save his company over $100,000 in the first year he implemented it.

Does your company need to learn good ideas (best practices) from industry leaders from around the world? Then register for the TapRooT® Summit at:

https://taproot.com/summit.php?t=register

Trevor Kletz, Professor at Loughborough University and safety guru from the UK, recently published an article titled: “Some Common Errors in Accident Investigations” in the Safety and Reliability Society Journal.

Four of the eight common errors he listed are:

1. They quote human error as the cause.
2. They blame individuals though many people have opportunities to prevent most accidents.
3. They do not realize that [corrective] actions are the most important part of a report.
4. The worst error: they think of a possible cause and then look for evidence that supports it.

Why do I bring up this article and these four errors here?

First, because I think that investigators could learn a lot from Trevor’s insights.

But second, because TapRooT® was developed to help prevent these four errors (and help with some of the ones not listed above too). Here’s how…

First, the TapRooT® Root Cause Tree® was developed to lead investigators past the common cause of human error to the real, fixable causes of human error.

Second, TapRooT®’s SnapCharT® diagram helps people see that there is not just one person to blame for an accident. It’s remarkable to see the investigation focus change from blame to understanding.

Third, the TapRooT® Corrective Action Helper® puts emphasis on developing effective corrective actions then the TapRooT® Software automatically includes the actions in the investigation report.

Finally, the TapRooT® System avoids the common cause-and-effect related error of jumping to conclusions by trying to prove a cause. Instead, TapRooT® starts with trying to understand what happened before de¬fining causal factors and then determining their root causes.

By design, TapRooT® helps beat common accident investigation errors.

Isn’t it time you tried TapRooT®?

See our public root cause analysis courses at:

www.taproot.com/courses

One of the highest rated sessions at the TapRooT® Summit is the “TapRooT® Users Share Root Cause Best Practices” session. Here’s a video of one TapRooT® User sharing an idea …

This idea may or may not apply to your investigations. But just one or two good ideas can “pay for” you Summit attendance by the benefits they create back at work. I had an attendee at the 2010 Summit tell me that one idea he learned was going to save his company over $100,000 in the first year he implemented it.

Does your company need to learn good ideas (best practices) from industry leaders from around the world? Then register for the TapRooT® Summit at:

https://taproot.com/summit.php?t=register

One of the highest rated sessions at the TapRooT® Summit is the “TapRooT® Users Share Root Cause Best Practices” session. Here’s a video of one TapRooT® User sharing an idea …

This idea may or may not apply to your investigations. But just one or two good ideas can “pay for” you Summit attendance by the benefits they create back at work. I had an attendee at the 2010 Summit tell me that one idea he learned was going to save his company over $100,000 in the first year he implemented it.

Does your company need to learn good ideas (best practices) from industry leaders from around the world? Then register for the TapRooT® Summit at:

https://taproot.com/summit.php?t=register

by Mark Paradies

Someone recently asked me:

“How is TapRooT® different from other root cause analysis tools?“

While answering the question, I concluded that it was the wrong question. The question should have been:

“Why is it that so many industry leaders have chosen TapRooT®
to be their standard for finding and fixing the root causes of problems?“

It’s not what makes TapRooT® different … It’s what makes TapTooT® clearly superior that should be the focus of the question and my answer.

Some people just don’t get this line of questioning. They say things like:

“Every techniques has its advantages and disadvantages.“

They just don’t understand that people can’t be trained in every technique.

Companies can’t afford to train everyone to be a guru problem solver.

Companies need a “best answer.” A root cause system that has been intelligently designed to meet the needs of the people in the field. People doing real investigations. A system they can adopt as a standard.

The techniques in this standard system need to be “human factored” – designed with the limitations and capabilities of the users in mind.

TapRooT® Design

When designing TapRooT®, Mark Paradies and Linda Unger not only used the human factors expertise that Mark brought to the development, but also worked with outstanding human factors experts (including Dr. Charles O. Hopkins and Smoke Price).

They human factored the TapRooT® System to make it usable. That makes it superior.

But the development efforts didn’t stop there.

Mark got reviews and comments from safety and reliability experts from a number of industries including aviation (Jerry Lederer, father of aviation safety), nuclear power and nuclear weapons (Larry Minnick, nuclear plant safety expert, and Paul Haas, DOE human factors & safety expert), and the oil/petrochemical business (Heinz Bloch, equipment reliability guru).

Those named are just a sample … not an exhaustive list. There were many more TapRooT® Users who helped in the early TapRooT® development efforts.
This made TapRooT® grow beyond one philosophy – beyond a single industry perspective.

Investigation + Root Cause Analysis

All this knowledge helped us develop not just a root cause analysis system, but something more … an investigation and improvement process that includes built-in human factored root cause analysis and troubleshooting tools.

When people tack root cause analysis on to an already completed investigation, they are missing the power of the techniques to help the investigator collect and evaluate investigative information.

That’s why TapRooT® is not just root cause analysis. TapRooT® is root cause analysis meshed with troubleshooting, an investigation process, and performance improvement processes (both reactive and proactive).

The whole system is made to work together seamlessly.

That’s different and superior!

Don’t Start Off Looking for “Why?”

I don’t want to give away all the secrets that make TapRooT® superior, but I will share a few more that should help people trying to decide if they should attend TapRooT® Training.

First, unlike many root cause analysis tools (think 5-Why’s or any cause-and-effect based system), TapRooT® doesn’t start out looking for “why” something happened. Instead, it starts out trying to understand “what” happened.

That’s a key difference.

One of the big drawbacks of many systems is that people using them jump to conclusions about why something happened before they understand what happened. It’s a natural human tendency. In fact, the more knowledge about a problem someone is, the more likely they are to think they automatically know the answer.

In TapRooT®, an investigator’s first goal is to build a complete SnapCharrT®.

A SnapCharT® visually shows what happened and as much information as can be gathered about the factors that surrounded what happened before one starts looking for root causes.

Users find this initial focus a major advantage because it helps them avoid the “blame trap” and the trap of jumping to conclusions.

Expert System Helps Investigators See Beyond Their Current Knowledge

The next major advantages of TapRooT® is the way TapRooT® looks at root causes and the tool used to guide investigators to the root causes of the problems causal factors.

In TapRooT®, we realized that accidents aren’t quite like falling dominoes. In fact, most accidents have multiple causes that existed prior to the accident and just never came together in the exactly wrong fashion at one point in time to cause the accident. Sometimes people call this coincidence “bad luck.” Engineers and statisticians may think of using Monte Carlo methods to simulate the seemingly randomness of real life.

Because of this, TapRooT® encourages investigators to identify all the causal factors and to find each causal factor’s root causes. Thus, there isn’t a “root cause” for an accident. Rather, there are multiple root causes for each causal factor that contributed to an accident.

Think about this as multiple opportunities to improve performance by improving multiple defenses to keep accidents from happening.

The tool used to analyze these causal factors is called the Root Cause Tree®. It is copyrighted and, in software form, patented. It is human factored to lead investigators to the root causes of human performance and equipment problems. Nobody has anything close to our tree.

Most of the development effort of the Root Cause Tree® was focussed on helping people in the field find the causes of human performance (including behavioral) problems.

The Root Cause Tree® is unique in the guidance it gives investigators in analyzing human performance issues including an expert system to start the troubleshooting of human errors, the categorization of best practices that is embedded in the tree, and the guidance for each category built into the Root Cause Tree® Dictionary.

Some say that the goal we set out for the Root Cause Tree® is impossible to achieve. We wanted to capture 90 – 98% of the root causes of human error in the categories on the tree. They say that it is impossible to include ALL the causes of human error in a model. Instead, they say that one should start out with an open mind and analyze each problem from scratch.

There are two problems with this argument.

First, the human brain thinks categorically. For example, the language we use to describe an accident is based on words (categories). So even if you try to start with an open mind, your brain is already categorizing.

We have found that the vast majority of investigators have not had specialized training in human factors. Therefore, they don’t know what they should be looking for (they don’t have the categories in their brain). This makes it almost impossible for them to identify the causes of human errors and develop effective corrective actions.

That’s why they revert to the standard answers of blame (counseling and discipline solutions), training, and, when all else fails, writing a procedure. It’s not that these answers are always wrong. It is that these answers are just a small fraction of what needs to be done to improve human performance. And the Root Cause Tree® provides a much more complete answer.

Second, we never said the Root Cause Tree® has all the answers.

The Root Cause Tree® is just the best list we’ve ever seen. We think it is closer to the 98% end of the scale than to the 90% end. And we know it is much more complete than the answers in the models carried in the heads of the people who come to our training.  Thousands of users that we train each year tell us that TapRooT®’s Root Cause Tree® expands the universe of problems they can find and solve …. It does not restrict their problem solving efforts.

Having designed TapRooT® and spent over 20 years improving it, I could go on with other major and minor advantages that we’ve worked so hard to incorporate into the TapRooT® System. But I’ll stop here with one more reason that TapRooT® is superior…

Continuous Improvement

We started with a great design but we didn’t stop.

We search for and implement ideas that make TapRooT® ever better, including ideas from international experts and our TapRooT® Advisory Board (60+ people from industry leading companies).

Better training, better software, and better techniques.

Continuous improvement keeps TapRooT® the state-of-the-art in root cause analysis and makes it superior.

TapRooT® as Your Root Cause Analysis Standard

Of course, there are more advantages to using TapRooT® – reasons that industry leaders around the world have standardized on just one method of root cause analysis. But by now you are probably thinking…

“Why haven’t we standardized on TapRooT® yet?”

Seems like a great idea.

Get started by attending one of our public TapRooT® Courses.

See the complete schedule at:

www.taproot.com/courses

These courses come with a money-back guarantee:

Attend a TapRooT® Course. Go back to work and apply what you have learned. If you don’t find root causes that you previously would have overlooked and if you and your boss don’t agree that you develop better corrective actions that are more effective, just return the course materials and any software supplied and we will refund the entire course fee.

That’s how confident we are that you will feel the difference.

TapRooT® isn’t just different, it’s superior.

Already Using TapRooT®? Get Better!

How do those that already use TapRooT® keep up with the newest TapRooT® improvements to sustain their programs and build on their success?

They attend the TapRooT® Summit.

That’s the best way to learn even more.

For information, see:

www.taproot.com/summit

and get registered!