Category: Root Causes

4 Root Cause Analysis Timesavers

September 23rd, 2015 by


I know how this works.  You get the notification that “something bad” happened, and you are assigned to perform a root cause analysis.  Your initial reaction is, “There goes the rest of my week!”

However, there is no reason that a relatively simple analysis needs to take an inordinate amount of time.  There are several things you can do to make sure that you can efficiently conduct the investigation, find solid root causes, and implement effective corrective actions.  Here are a few ideas to help you make the process as smooth as possible.

1.  The first thing that needs to be in place is a Detailed Investigation Policy for your company.  When does a RCA need to be performed?  What types of problems trigger an RCA?  What is the decision-making chain of command?  Who makes the notifications?  Who is notified?  Who will be on the team?  All of these questions need to be easily answered in order to quickly get the process started.  I have seen investigators receive notification of a problem over a week after the actual incident.  By this time, evidence has been lost, key players are no longer available, and peoples’ memories have faded.  All of this makes the investigation just that much harder.  If you can streamline this initial decision-making and notification process so that the investigation can start within hours, you’ll find the actual investigation goes MUCH more smoothly.

2.  Probably the biggest timesaver is to Be Proficient in the TapRooT® Process.  We recommend you use TapRooT® at least once per month to maintain proficiency in the system.  You can’t be good at anything if you only use it sparingly.  I often hear people tell me, “Luckily, we don’t have enough incidents to use TapRooT® more than once per year.”  Imagine if I asked you to put together an Excel spreadsheet using pivot tables, and you haven’t opened Excel since 2014!  You’d have to relearn some key concepts, slowing you down.  The same is true of an investigation process.  If you only do an investigation once each year, you aren’t looking very hard for incidents.  I’ll guarantee there are plenty of things that need to be analyzed.  Each analysis makes you that much better at the process.  Maybe go back to point #1 above and update your investigation trigger points.

3.  When you actually get started on an investigation, the first thing you should do is Start A Spring SnapCharT®.  This initial chart gets your investigator juices flowing.  It helps you think about the timeline of the incident, identifying holes in your knowledge and questions you need to ask in order to fill those holes.  It is the first step in the process.  As soon as you get that initial phone call, start building your SnapCharT®!

4.  Finally, although it is optional, The TapRooT® Software can really speed up your analysis.  The SnapCharT® tool is extremely user friendly, and the Root Cause Dictionary is only a right-click away.  It guides you through the investigation process so you don’t have to try to remember where you’re going.

You won’t perform an investigation in 5 minutes.  However, by following these tips, you relatively quickly and efficiently move through the process, with terrific results.

To learn more about learning all of the essential techniques to perform a root cause investigation, read about our 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course.

Why What You Think About Root Cause Training is Wrong

August 5th, 2015 by


People are often surprised when they learn the reasons they haven’t taken root cause analysis training are invalid.  Here are the top three excuses people give that are wrong:

1. Most employers aren’t seeking that skill when hiring.

Root cause analysis is a top skill valued by employers because mistakes don’t “just happen” but can be traced to well-defined causal factors that can be corrected.  A bonus to root cause analysis training is that root causes identified over time across multiple occurrences can be used for proactive improvement. For example, if a significant number of investigations point to confusing or incomplete SPAC (Standards, Policies, or Admin Controls), improvement of this management system can begin. Trending of root causes allows development of systematic improvements as well as evaluation of the impact of corrective actions.  What boss doesn’t appreciate an employee who can prevent HUGE problems and losses from occurring?  Promoting your root cause analysis skills is an impressive topic of conversation on any job interview.

2. It takes too long to learn enough to really use it on my job.

In just 2 days you can learn all of the essentials to conduct a root cause analysis and add this impressive skill to your resume.  You will be equipped to find and fix the root causes of incidents, accidents, quality problems, near-misses, operational errors, hospital sentinel events and other types of problems.  The essential TapRooT® Techniques include:

  • SnapCharT® – a simple, visual technique for collecting and organizing information to understand what happened.
  • Root Cause Tree® – a systematic, repeatable way to find the root causes of human performance and equipment problems — the Root Cause Tree® helps investigators see beyond their current knowledge.
  • Corrective Action Helper® – help lead investigators “outside the box” to develop effective corrective actions.

There are all kinds of training programs you can enroll in for your career development that take months, even years, to complete.  A 2-day investment for this valuable training program will equip you with a powerful skill that will set you apart from the rest.

3. I don’t have enough technical knowledge to take training like that.

It doesn’t matter if you have a high school diploma or an MBA.  It doesn’t matter if you do not know much about root cause analysis beyond the description provided below.  Our attendees, at every level of education and technical skill, find that they can engage in the training and take away root cause analysis skills to implement immediately.  It is not a “sit and listen” training – attendees do hands on exercises to develop their new knowledge in the course.

Root cause analysis is a systematic process used in investigating and fixing the causes of major accidents, everyday incidents, minor near-misses, quality issues, human errors, maintenance problems, medical mistakes, productivity issues, manufacturing mistakes and environmental releases.

Root cause analysis training provides:

  • the knowledge to identify what, how and why something happened, and this knowledge is vital to preventing it from happening again.
  • the understanding that root causes are identifiable and can be managed with corrective actions.
  • an ease of data collection, root cause identification, and corrective action recommendations and implementation.

Still not convinced root cause analysis training is for you?

GUARANTEE for the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course: Attend this 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.

CLICK HERE to register for the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course.

Root Cause Analysis Tip: 6 Reasons to Look for Generic Root Causes

July 22nd, 2015 by


“Allowing generic causes to fester can sometimes cause similar problems to pop up in unexpected areas.”

You have established a good performance improvement program, supported by performing solid incident investigations.  Your teams are finding good root causes, and your corrective action program is tracking through to completion.  But you still seem to be seeing more repeat issues than you expect.  What could be the problem?

We find many companies are doing a great job using TapRooT® to find and correct the root causes discovered during their investigations.  But many companies are skipping over the Generic Cause Analysis portion of the investigation process.  While fixing the individual root causes are likely to prevent that particular issue from happening again, allowing generic causes to fester can sometimes cause similar problems to pop up in unexpected areas.

6 Reasons to Look for Generic Root Causes

Here are 6 reasons to conduct a generic cause analysis on your investigation results:

1. The same incident occurs again at another facility.

2. Your annual review shows the same root cause from several incident investigations.

3.  Your audits show recurrence of the same behavior issues.

4. You apply the same corrective action over and over.

5. Similar incidents occur in different departments.

6. The same Causal Factor keeps showing up.

These indicators point to the need to look deeper for generic causes.  These generic issues are allowing similar root causes and causal factors to show up in seemingly unrelated incidents.  When management is reviewing incident reports and audit findings, one of your checklist items should be to verify that generic causes were considered and either addressed or verified not to be present.  Take a look at how your incident review checklist and make sure you are conducting a generic cause analysis during the investigation.

Finding and correcting generic causes are basically a freebie; you’ve already performed the investigation and root cause analysis.  There is no reason not to take a few extra minutes and verify that you are fully addressing any generic issues.

Learn more about finding and fixing root causes in our 2-day or 5-day TapRooT® Root Cause Analysis courses!

IT/Computer Problems and Root Cause Analysis

July 8th, 2015 by

United grounds all of their flights for two hours due to “computer problems” (see the CNBC story). 

The NYSE stops trading for over three hours due to an “internal technical issue” (see the CNBC story).

Computer issues can cost companies big bucks and cause public relations headaches. Do you think they should be applying state of the art root cause analysis tools both reactively and proactively to prevent and avoid future problems?

TapRooT® has been used to improve computer reliability and security by performing root cause analysis of computer/IT related events and developing effective corrective actions. The first TapRooT® uses for computer/high reliability network problems where banking and communication service providers that started using TapRooT® in the late 1990’s. The first computer security application of TapRooT® that we knew about was in the early 2000s. 

Need to improve your root cause analysis of computer and IT issues? Attend one of our TapRooT® Root Cause Analysis Courses. See the upcoming course schedule at:

Robot Made a Human Error and a Worker was Killed

July 8th, 2015 by


The 22-year-old man died in hospital after the accident at a plant in Baunatal, 100km north of Frankfurt. He was working as part of a team of contractors installing the robot when it grabbed him, according to the German car manufacturer. Volkswagen’s Heiko Hillwig said it seemed that human error was to blame.

A worker grabs the wrong thing and often gets asked, “what were you thinking?” A robot picks up the wrong thing and we start looking for root causes.

Read the article below to learn more about the fatality and ask why would we not always look for root causes once we identify the actions that occurred?


Would you know if your corrective action resulted in an accident?

June 30th, 2015 by

“Doctor… how do you know that the medicine you prescribed him fixed the problem,” the peer asked. “The patient did not come back,” said the doctor.

No matter what the industry and or if the root causes found for an issue was accurate, the medicine can be worse than the bite. Some companies have a formal Management of Change Process or a Design of Experiment Method that they use when adding new actions.  On the other extreme, some use the Trial and Error Method… with a little bit of… this is good enough and they will tell us if it doesn’t work.

You can use the formal methods listed above or it can be as simple for some risks to just review with the right people present before implementation of an action occurs. We teach to review for unintended consequences during the creation of and after the implementation of corrective or preventative actions in our 7 Step TapRooT® Root Cause Analysis Process. This task comes with four basic rules first:

1. Remove the risk/hazard or persons from the risk/hazard first if possible. After all, one does not need to train somebody to work safer or provide better tools for the task, if the task and hazard is removed completely. (We teach Safeguard Analysis to help with this step)

2. Have the right people involved throughout the creation of, implementation of and during the review of the corrective or preventative action. Identify any person who has impact on the action, owns the action or will be impacted by the change, to include process experts. (Hint, it is okay to use outside sources too.)

3. Never forget or lose sight of why you are implementing a corrective or preventative action. In our analysis process you must identify the action or inaction (behavior of a person, equipment or process) and each behaviors’ root causes. It is these root causes that must be fixed or mitigated for, in order for the behaviors to go away or me changed. Focus is key here!

4. Plan an immediate observation to the change once it is implemented and a long term audit to ensure the change sustained.

Simple… yes? Maybe? Feel free to post your examples and thoughts.

Product Safety Recall…… one of the few times that I see Quality and Safety Merge

June 22nd, 2015 by

We can all remember some type of major product recall that affected us in the past (tires, brakes, medicine….) or recalls that may be impacting us today (air bags). These recalls all have a major theme, a company made something and somebody got hurt or worse. This is a theme of “them verses those” perception.

Now stop and ask, when is the last time quality and safety was discussed as one topic in your current company’s operations?

You received a defective tool or product….

  1. You issued a defective tool or product….
  2. A customer complained….
  3. A customer was hurt….
  4. ???….

Each of the occurrences above often triggers an owner for each type of problem:

  1. The supplier…
  2. The vendor…
  3. The contractor…
  4. The manufacturer….
  5. The end user….

Now stop and ask, who would investigate each type of problem? What tools would each group use to investigate? What are their expertise and experiences in investigation, evidence collection, root cause analysis, corrective action development or corrective action implementation?

This is where we create our own internal silo’s for problem solving; each problem often has it’s own department as listed in the company’s organizational chart:

  1. Customer Service (Quality)
  2. Manufacturing (Quality or Engineering)
  3. Supplier Management (Supply or Quality)
  4. EHS (Safety)
  5. Risk (Quality)
  6. Compliance (?)

The investigations then take the shape of the tools and experiences of those departments training and experiences.

Does anyone besides me see a problem or an opportunity here?

Remembering An Accident: Norco, Louisiana Oil Refinery Explosion

May 5th, 2015 by

On May 5, 1988, one of United States’ worst oil refinery explosions occurred in Norco, Louisiana. There were six employees that were killed and 42 local residents injured. The blast was said to have reached up to 3o miles away shattering windows, lifting roofs and sending a black fog over the entire town of Norco. Residents were forced to evacuate while officials died the fires down and gathered as much rubble as possible to recover any bodies. In order to discover the root cause of this disaster, the Federal Occupational Health and Safety Administration as well as the Environment Protection Agency came and investigated the scene to gather information. The only possible root cause they could find was the catalytic cracking unit, machine used to break down crude oil into gasoline, because it was at the center of the explosion, but there was no definite cause found. Overall, the amount of damage done cost Shell millions of dollars and set an incredible amount of fear into the residents.



Read here for the full story and direct quotes in the New York Times. 

How Did the TapRooT® Root Cause Analysis System Get So Far Ahead of the Rest?

April 28th, 2015 by

I was at a conference yesterday and one of the talks was about advanced root cause analysis. The presenter’s company had their own “home grown” root cause analysis system and they discovered that they were not getting consistent results. Improvement was needed!

They studied their system and discovered something that was missing – management system causes. In the TapRooT® System we have called these “Generic Causes” since we copyrighted the first TapRooT® manual in 1991. 

It made me think … Why did they wait 24 years to discover something we’ve known about since before 1991?

Next, I talked with an engineer who had been trained in a common cause and effect system. He wasn’t too pleased with the results he was getting. He wanted to know how TapRooT® could help. Was it different?

I shared how TapRooT® works (see this LINK for the explanation) and it took quite a bit of effort to get beyond the cause and effect model that he thoroughly understood so that he could understand why he was missing things. He was really smart. He asked very insightful questions. He latched onto the reasons that the less systematic cause and effect analysis led to inconsistent results. He saw how TapRooT® could help investigators go beyond their paradigm and get consistent results. 

By the end of this second conversation I started thinking … How did we get so far ahead of common root cause systems?

I think I know the answer.

It starts with the Human Factors training that I received at the University of Illinois. It really showed me how to think about human centered design – including designing a root cause analysis system that people could use consistently.

Second, I was fortunate enough to work in the Nuclear Navy where there was an excellent process safety culture and for Du Pont where there was an excellent industrial safety culture. This helped me see how management systems made a difference to performance. (My boss and I at Du Pont actually coined the phrase “Management System” that is now commonly used throughout industry.)

Third, I was well trained by my mentor at the University of Illinois, Dr. Charles O. Hopkins, how to do applied research. So the research I did studying root cause analysis in the mid-1980’s and early 1990’s really paid off when we created the TapRooT® System.

Fourth, we had a really good team that brought out the best in each other during the early development.

Next, we were lucky to have some excellent clients in the nuclear, oil, and aviation industries that were great early adopters and provided excellent feedback that we used to quickly improve TapRooT® root cause analysis in the early and mid-1990’s. 

Finally, I made friends with and/or listened to many industry gurus who were experts in safety, process safety, quality, and equipment reliability. Their influence was built into TapRooT® and helped it be a world-class system even in it’s early stages. These experts included:

  • Jerry Ledderer, aviation safety pioneer
  • Dr. Charles O. Hopkins, human factors pioneer
  • Smoke Price, human factors expert
  • Larry Minnick, nuclear safety expert
  • Rod Satterfield, nuclear safety expert
  • Dr. Alan Swain, human reliability expert
  • Heinz Bloch, equipment reliability expert
  • Admiral Hyman Rickover, father of the Nuclear Navy and process safety expert
  • Dr. Christopher Wickens, human factors expert
  • Dr. Jens Rassmussen, system reliability and human factors expert
  • W. Edwards Deming, quality management guru
  • Admiral Dennis Wilkerson, first CO of the Nautilus and first CEO of INPO

That’s quite a list and I was lucky to be influenced by each of these great men. Their influence made TapRooT® root cause analysis far ahead of any other root cause tool.

So that’s why I shouldn’t be surprised that others are finally catching on to things that we knew 25 years ago. Perhaps in a century, they will catch up with the improvements we are making to TapRooT® today (with the help of thousands of users from around the world). 

If you would like to learn the state-of-the-art of root cause analysis and not wait 25 to 100 years to catch up, perhaps you should attend a TapRooT® Course in the next month or two. See our course schedule for upcoming public courses at:

And get information about all the courses we offer at:

And if you would like to learn about the state of the art of performance improvement, attend the 2015 TapRooT® Summit coming up on June 1-5 in Las Vegas. Get more information and download the brochure at:

 But don’t wait. Every day you wait you will be another day behind the state-of-the-art in root cause analysis and performance improvement. Don’t be left behind!

TapRooT® Root Cause Analysis
Changing the Way the World Solves Problems



Even in Humor, You can learn about Root Cause and People from Dr. Deming

January 22nd, 2015 by

Caution: Watching this Video can and will make you laugh…… then you realize you might be laughing at…

… your own actions.

… your understanding of other peoples actions.

… your past corrective or preventative actions.

Whether your role or passion is in safety, operations, quality, or finance…. “quality is about people and not product.” Interestingly enough, many people have not heard Dr. Deming’s concepts or listened to Dr. Deming talk. Yet his thoughts may help you understand the difference between people not doing their best and the best the process and management will all to be produced.

To learn more about quality process thoughts and how TapRooT® can integrate with your frontline activities to sustain company performance  excellence, join a panel of Best Practice Presenters in our TapRooT® Summit Track 2015 this June in Las Vegas. A Summit Week that reminds you that learning and people are your most vital variables to success and safety.

To learn more about our Summit Track please go to this link.

If you have trouble getting access to the video, you can also use this link

PC World Headline: “Human error root cause of November Microsoft Azure outage”

December 18th, 2014 by

There they go again. HUMAN ERROR as a root cause.

See the story at:

Haven’t they read my article at:

Human error is a symptom, not the root cause.

Attend a TapRooT® Course and find out how you can find and fix the real causes of human error.

TapRooT® Terms and Definitions

December 5th, 2014 by

When using TapRooT®, most of the terms are pretty self-explanatory. TapRooT® is pretty easy to understand and use. However, there are a few terms that we use that may be a little different than those you might be used to. I thought I’d give a few definitions to help make things just a little bit clearer.

Root Cause Tree®: This is the heart of the TapRooT® system. It is contains the guidance and the root causes needed by the investigator.

Root Cause Dictionary®: Contains a list of bulleted yes/no questions that guide your investigator through the Root Cause Tree®.

SnapCharT®: This is a visual representation of the investigation. It is used to document the evidence you find during your investigation, allows you to identify Causal Factors, and is used with the Root Cause Tree® during the analysis. It contains the Incident, Event, and Condition shapes.

Incident: This is the reason you are performing the investigation. It is the problem that lead you to start your TapRooT® process. It is a circle on your SnapCharT®.

Event: An action performed by someone or a piece of equipment. They are arranged in chronological order as rectangles on the SnapCharT®.

Condition: A piece of information that describes the Event that it is attached to. Represented by an oval on the SnapCharT®.

Root Cause: The absence of best practices or the failure to apply knowledge that would have prevented the problem (or significantly reduced the likelihood or consequences of the problem).

Causal Factor: Mistake or failure that, if corrected, could have prevented the Incident from occurring, or would have significantly mitigated its consequences.

Generic Cause: A systemic problem that allows a root cause to exist.

Tulsa Public 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

November 4th, 2014 by

Final case studies being presented in our Tulsa, Oklahoma course.

Image 4 Image 5 Image 6 Image 7

For more information on our public courses click here or to book your own onsite course click here.

San Antonio 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

November 4th, 2014 by

Students presenting their final case studies on day 5 of the course. Students always learn something new in the case that they brought to be reviewed.

Image Image 1 Image 3Image 2

For more information on our public courses click here or to book your own onsite course click here.

Airplane Crashes: Pilot and People in a Simulator Die

November 4th, 2014 by


Airplane loses power during take off at a Kansas Airport and plane strikes building. Pilot of the King Air Aircraft that crashed and 3 people working in a flight simulator inside that building are dead. Read more here at KAKE News in Wichita, KS.

I post this because of the debates and blame that are going to ensue. Was it just one thing, the plane crashing, that caused this issue to occur? Was it the location of all the flight buildings in the vicinity of an airport. Was this just a “freak accident”. So much more to learn… I hope they get it right so it does not happen again.

8 Reasons to Ask for Help with an Investigation

October 28th, 2014 by

People who attend TapRooT® Training know that trainees are expected to go back to work as self-sufficient investigators. They should be able to perform an excellent root cause analysis without an outside facilitator.

But there can be times when an investigator needs to ask for help. When should you ask for help with an investigation?

Here are eight examples that could help you decide when to ask for help:


Could this accident end up in court? If so, you need the help of your company’s attorney.

They may need to be involved BEFORE the investigation starts to establish “attorney/client privilege.” In these cases, the attorney may want to hire an outside expert to review the company’s investigation and help spot potential weaknesses before legal action starts.


It’s always tough when a customer has a problem and blames your product. What do you do if you think that the product was OK but, instead, the customer’s actions caused the problem? Root cause analysis could be a big help.

But will the customer believe the results of your employees’ investigation? This is a good time to get an outside facilitator to provide an independent perspective or lead a joint customer/supplier investigation.


Ever had an investigation that gets contentious with a union?

This may be time to ask for help. An outside facilitator provides an independent perspective and can help both sides see how to achieve improvement. This can be a win-win investigation.


TapRooT® Training is a great start for a new investigator. But, as we say in the course, get your feet wet when you go back to work by performing some easy investigations.

What if a complex accident happens when you are newly training? Ask for help! Get an experienced investigator to help you facilitate the investigation or to review your work and coach you.

What if you don’t have any experienced investigators at your site? Call SI at 865-539-2139. We have experienced investigators who can help.


Sometimes management may want a fresh set of eyes to look at a problem. An independent investigator may bring a different background, new knowledge, and the ability to see beyond “that’s the way we’ve always done it.” This can challenge “common knowledge” and go beyond groupthink.


I’ve seen investigations that might result in someone in upper management losing their job. Nobody wanted to be on the investigation team because they didn’t want to be the one who got a senior manager fired. (Payback from friends of the one fired is a real problem.) So an independent investigator could step into this controversial situation without fear of retribution.


Even if your investigations aren’t too hard, you may want to hire our experienced investigators to provide feedback (coaching) on your “everyday” investigations so that your investigators constantly improve. If this sounds helpful, once again, give us a call.


Too many accidents to investigate? Augment your staff with facilitators to help investigate incidents and provide your investigators with valuable feedback.

Again, we can help. Our 40+ experienced TapRooT® Investigators from around-the-world provide help when you need it.

Still not sure? Contact us at: for more information.

Throwback Thursday: Scotland

August 21st, 2014 by

Throwing it a few years back to the wonderful course in Aberdeen, Scotland in 2010! What an awesome learning experience these instructors had working on the new SnapChart® Exercise to enhance their TapRooT® skills. What have been your experiences with this innovative exercise for incident investigations? Leave a comment below to share your story!

Aberdeen Fun Fact: Aberdeen Harbour Board is the oldest business in Britain. It was established in 1136 and now handles around four million tons of cargo every year serving approximately 40 countries worldwide!


Interested to learn more? Sign-up for a course near you! Just click here for more information about available courses.

Food Industry Related OSHA General Duty Clause Citations: Did you make the list? Now what?

August 13th, 2014 by

OSHA General Duty Clause Citations: 2009-2012: Food Industry Related Activities


Doing a quick search of the OSHA Database for Food Industry related citations, it appears that Dust & Fumes along with Burns are the top driving hazard potentials.

Each citation fell under OSH Act of 1970 Section 5(a)(1): The employer did not furnish employment and a place of employment which were free from recognized hazards that were causing or likely to cause death or serious physical harm to employees in that employees were exposed……

Each company had to correct the potential hazard and respond using an Abatement Letter that includes words such as:

The hazard referenced in Inspection Number [insert 9-digit #]

for violation identified as:

 Citation [insert #] and item [insert #] was corrected on [insert

date] by:


Okay so you have a regulatory finding and listed above is one of the OSHA processes to correct it, sounds easy right? Not so fast…..

….are the findings correct?

….if a correct finding, are you correcting the finding or fixing the problems that allowed the issue?

….is the finding a generic/systemic issue?

As many of our TapRooT® Client’s have learned, if you want a finding to go away, you must perform a proper root cause analysis first. They use tools such as:


o   SnapCharT®: a simple, visual technique for collecting and organizing information quickly and efficiently.

o   Root Cause Tree®: an easy-to-use resource to determine root causes of problems.

o   Corrective Action Helper®: helps people develop corrective actions by seeing outside the box.

First you must define the Incident or Scope of the analysis. Critical in analysis of a finding is that the scope of your investigation is not that you received a finding. The scope of the investigation should be that you have a potential uncontrolled hazard or access to a potential hazard.

In thinking this way, this should also trigger the need to perform a Safeguard Analysis during the evidence collection and during the corrective action development. Here are a few blog articles that discuss this tool we teach in our TapRooT® Courses.

Monday Accident & Lesson NOT Learned: Why Do We Use the Weakest Corrective Actions From the Hierarchy of Safeguards?

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

If you have not been taking OSHA Finding to the right level of action, you may want to benchmark your current action plan and root cause analysis process, see below:



Benchmark Your Root Cause Analysis Efforts

July 30th, 2014 by


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

  • Bad
  • Better
  • Even Better
  • Excellent

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

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


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

Who performs the root cause analysis? The supervisor involved.

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

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

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

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

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


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

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

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



Better is better than bad, but still has problems.

Who performs the root cause analysis? The supervisor involved.

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

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

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

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

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


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

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



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

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

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

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

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

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

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


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

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




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

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

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

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

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

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

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


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

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



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

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.

Want to see more tips like these? Subscribe to our Tuesday eNewsletter.  It delivers a root cause tip column, career development tips, accidents & lessons learned and more!  Just send an email to Barb at with “subscribe” in the subject line.

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:

Should You Attend the Global TapRooT® Summit if You’re Not TapRooT® Trained?

October 17th, 2013 by

2012-TapRooT®-Summit-110.JPGIf you’ve been following our blog lately, you’ve noticed we’ve been busy preparing for the 2014 Global TapRooT® Summit (Horseshoe Bay, Texas, April 7 – 11, 2013).

You may have even considered signing up. I mean, who wouldn’t want to stay at the AAA Four Diamond Horseshoe Bay Resort (maybe even bring your spouse and enjoy it as a couple).

Who wouldn’t want to win great prizes, and enjoy a (literally) rock star Wednesday night reception?

And just how many chances in life do you get to meet and hear world-class speakers like Rocky Bleier?

But just when you were about to press the registration button, you thought:

Wait, I’m not sure I understand all there is to understand about TapRooT® Root Cause Analysis.
Since the TapRooT® folks are putting this together, shouldn’t I be TapRooT® trained before I attend?

First, if you are not TapRooT® trained, come to the 3-day Summit anyway.  Multiple tracks designed to share best practices within and across industries and professions make this event valuable to all. There are plenty of best practice session to choose from and you can create your own schedule if you don’t want to select a specific learning track.

And second, you can actually be TapRooT® trained before the 3-day Summit begins! We’re offering our 2-Day TapRooT® Incident Investigation & Root Cause Analysis Pre-Summit Course on April 7-8, 2014 as a Pre-Summit Course!

TapRooT® Techniques are designed for everyone from beginner to expert. In just two days, learn the TapRooT® Essentials to find and fix the root causes of incidents, accidents, quality problems, near-misses, operational errors, hospital sentinel events and other types of problems.

The essential TapRooT® Techniques include:

  • SnapCharT® – a simple, visual technique for collecting and organizing information to understand what happened.
  • Root Cause Tree® – a systematic, repeatable way to find the root causes of human performance and equipment problems — the Root Cause Tree® helps investigators see beyond their current knowledge.
  • Corrective Action Helper® – help lead investigators “outside the box” to develop effective corrective actions.

Using the TapRooT® System to find and fix the real root causes of problems keeps them from happening again and again.

So take our 2-Day course and then reinforce your new knowledge at the Summit by registering for the Incident Investigation and Root Cause Analysis Track. Make it a week of valuable learning that will contribute not only to your personal career development but also to saving lives and preventing injuries at your facility.

This is the same course we offer globally throughout the year, and what better time is there to join the global TapRooT® team than right before the Summit where all of our friends and experts meet?

Register for this Pre-Summit Course and the Summit today!

Or learn more about the 2014 Global TapRooT® Summit!


Interesting Article at the BST Web Site About Discipline and Safety

September 26th, 2013 by

When many people first see the “enforcement NI” root cause on the TapRooT® Root Cause Tree®, they think that the obvious corrective action would be discipline. But those who read the TapRooT® Corrective Action Helper® know that there are reasons for people violating rules and that the only way to truly change behavior is to address the reasons why the rules are being broken.

The article, “The Five Pitfalls of Discipline in Safety,” clearly presents reasons why enforcement might need improvement. Click on the link and see if you agree.

Connect with Us

Filter News

Search News


Barb PhillipsBarb Phillips

Editorial Director

Chris ValleeChris Vallee

Six Sigma

Dan VerlindeDan Verlinde

Software Development

Dave JanneyDave Janney

Safety & Quality

Ed SkompskiEd Skompski


Gabby MillerGabby Miller

Communications Specialist

Ken ReedKen Reed


Linda UngerLinda Unger

Vice President

Mark ParadiesMark Paradies

Creator of TapRooT®

Steve RaycraftSteve Raycraft

Technical Support

Success Stories

Fortunately, I had just been introduced to a system for incident investigation and root cause analysis…

Enmax Corporation

Four years ago I was an incident investigator, an incident reviewer, and an investigation techniques…

Hydro One
Contact Us