Category: TapRooT

Are Your Corrective Actions Designed to Prevent Future Incidents?

October 14th, 2015 by

I had a great conversation with one of our clients today. He mentioned that, with the price of oil below $50/barrel, his company is being proactive and looking at ways to improve their processes.  One thing that they’re doing is reviewing old incidents and seeing where the commonalities lie.  One item of interest that they found:  They have discovered several instances of repeat problems.  They found root causes, but they seem to pop up again.

What they are doing is what we call a Generic Cause analysis.  They are looking deeper at their data and finding opportunities for improvement.

A review of the corrective actions found quite a few that seemed to be more akin to immediate actions than corrective actions.  For example, if there was a production shutdown that was caused by a failed valve, the corrective action was, “Remove and repair the faulty valve.”  Now, I’m not saying that this is necessarily a bad idea.  However, is this corrective action aimed at preventing future recurrence of the incident?  This corrective action, by itself, is designed more to restore plant operation, not prevent future issues.

Remarkably, this turned out to be more a terminology issue than a failure of their system.  When asked about this, the Corrective Action team said, “Oh, you want actions that will prevent the incident in the future?  Then you aren’t asking for ‘corrective actions’; you are asking for ‘preventative actions.’  You have to be clear what you want.”

TapRooT® does not really distinguish between these types of fixes.  We expect all of these actions to be developed.  We find that the “corrective actions” noted above are designed to fix the Causal Factor (“Valve failed to open.  Therefore, repair the valve.”).  This is as far as most other “root cause analysis” systems go, since they normally only get to the causal factor level.


While you DO need to fix these issues, we also want you to continue to assign corrective actions to actual root causes.  If the valve failed because the repair procedure specified the incorrect part (in TapRooT®, this root cause would be “facts wrong”), and you would therefore put a corrective action in place to fix this human-performance problem (“Update repair standard to indicate the correct gasket part number 885-33425″).  This will fix not just this particular valve, but any valves in the future that are repaired using this same repair procedure.  Without this corrective action, you will see this same issue pop up again as we continue to improperly repair valve failures.

Make sure you and your investigation teams are all on the same page.  We use the term “Corrective Action” to indicate any and all actions that are designed to fix problems.  Corrective Actions include those actions that fix the general issue (failed valve), and those that are designed to prevent the issue from occurring again in the future (procedure wrong).  Take a look at your systems and make sure you are fixing both types of problems.

Sign up to receive tips like these in your inbox every Tuesday. Email Barb at and ask her to subscribe you to the TapRooT® Friends & Experts eNewsletter – a great resource for refreshing your TapRooT® skills and career development.

Get More from TapRooT®: Follow our Pages on LinkedIn

August 13th, 2015 by

Do you like quick, simple tips that add value to the way you work? Do you like articles that increase your happiness?  How about a joke or something to brighten your day? Of course you do! Or you wouldn’t be reading this post.  But the real question is, do you want MORE than all of the useful information we provide on this blog?  That’s okay – we’ll allow you to be greedy!

A lot of people don’t know we have a company page on LinkedIn that also shares all those things and more.  Follow us by clicking the image below that directs to our company page, and then clicking “Follow.”


We also have a training page where we share tips about career/personal development as well as course photos and information about upcoming courses.  If you are planning to attend a TapRooT® course or want a job for candidates with root cause analysis skills, click the image below that directs to our training page and then click “Follow.”

training page

Thank you for being part of the global TapRooT® community!

Final presentations at the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course

July 24th, 2015 by

Great work by all participants! Here’s one of the presentations and the audience …

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We Train Great Leaders

July 21st, 2015 by

Click the light gray box near the bottom right corner to view larger slideshow.

The more things change the more they stay the same…

July 21st, 2015 by

I overheard a senior executive talking about the problems his company was facing:

  • Prices for their commodity were down, yet costs for production were up.
  • Cost overruns and schedule slippages were too common.
  • HSE performance was stagnant despite improvement goals.
  • They had several recent quality issues that had caused customer complaints.
  • They were cutting “unnecessary” spending like training and travel to make up for revenue shortfalls. 

I thought to myself … 

“How many times have I heard this story?”

I felt like interrupting him and explaining how he could stop at least some of his PAIN. 

I can’t do anything about low commodity prices. The price of oil, copper, gold, coal, or iron ore is beyond my control. And he can’t control these either.

 But he was doing things that were making his problems (pain) worse. 

For example, if you want to stop cost overruns, you need to analyze and fix the root causes of cost overruns.

How do you do that? With TapRooT®.

And how would people learn about TapRooT®? By going to training.

And what had he eliminated? The training budget!

How about the stagnant HSE performance?

To improve performance his company needs to do something different. They need to learn best practices from other industry leaders from their industry AND from other industries.

Where could his folks learn this stuff? At the TapRooT® Summit.

His folks didn’t attend because they didn’t have a training or travel budget!

And the quality issues? He could have his people use the same advanced root cause analysis tools (TapRooT®) to attack them that they were already using for cost, schedule, and HSE incidents. Oh, wait. His people don’t know about TapRooT®. They didn’t attend training.

This reminds me of a VP at a company that at the end of a presentation about a major accident that cost his company big $$$$ and could have caused multiple fatalities (but they were lucky that day). The accident had causes that were directly linked to a cost cutting/downsizing initiative that the VP had initiated for his division. The cost cutting initiative had been suggested by consultants to make the company more competitive in a down economy with low commodity prices. At the end of the presentation he said:

“If anybody would have told me the impacts of these cuts, I wouldn’t have made them!”

Yup. Imaging that. Those bad people didn’t tell him he was causing bad performance by cutting the people and budget they needed to make the place work. 

That accident and quote occurred almost 20 years ago.

Yes, this isn’t the first time we have faced a poor economy, dropping commodity prices, or performance issues. The more things change, the more they stay the same!

But what can you do?

Share this story!

And let your management know how TapRooT® Root Cause Analysis can help them alleviate their PAIN!

Once they understand how TapRooT®’s systematic problem solving can help them improve performance even in a down economy, they will realize that the small investment required is well worth it compared to the headaches they will avoid and the performance improvement they can achieve.

Because in bad times it is especially true that:

“You can stop spending bad money
or start spending good money
fast enough!”


People Hard at Work at the 5-Day Advanced Root Cause Analysis Team Leader Course in Seattle

July 20th, 2015 by

It’s day one of the 5-Day Advanced Root Cause Analysis Team Leader Course in Seattle and folks are hard at work in their first exercise using the Root Cause Tree® Diagram to find the root causes of an incident.

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VIEW MORE PHOTOS of this course:

Do you need advanced root cause analysis training? See out worldwide public 5-Day TapRooT® Course schedule at:

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?


TapRooT® in Chile

July 8th, 2015 by

Marco Flores


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Chile Wins Cup!

TapRooT® Instructor Marco Flores sent us this great photo from a recent course in Chile and reported that Chile recently won the America Cup in soccer for the first time in 105 years!

Congratulations to our Chilean friends!



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.

Public TapRooT® Course in India

June 25th, 2015 by

1280px-Marine_Drive_Kochi_Night_View_DSWOn August 3, 2015, join TapRooT® for a 5-Day Advanced Root Cause Analysis and Team Leader Training public course in Cochin, Ernakulam, India for the ONLY time in 2015. This course is filled with excellent industry training and material that is well worth the investment for you and your company.

Cochin, also referred to as Kochi or Ernakulam, is known as the Queen of the Arabian Sea due to its spice trading on the west coast. Cochin is also the second largest and highest populated city in the area making it the home of major chemical and electrical industries, the Indian Naval Headquarters and offshore refineries (pictured below).


It’s a great trip for everyone! Bring the whole team for Root Cause Analysis Training and bring the whole family to enjoy the attractions and rich culture that Cochin, India has to offer.

A few fun attractions they have to offer:

Wonderla: From water rides to thrilling rides to kid-friendly rides, this amusement park is a fun attraction for the family.

LuLu Mall: Take a break from the heat and visit this giant mall filled with movies, shopping and food!

Folklore Museum: Step back in time with these anthropology, ethnography and architectural exhibits.

Don’t forget, this is the only time this year that you can attend TapRooT® training in this region, so register today before the seats fill up.

Want more information on the TapRooT® 5-Day course? Click here.

Ready to register and take advantage of this incredible opportunity? Click here

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?

Do You Have the Newest Editions of the TapRooT® Root Cause Dictionary, Root Cause Tree and Corrective Action Helper?

May 20th, 2015 by

2015 DuoCahA new revision of the TapRooT® Root Cause Dictionary, TapRooT® Root Cause Tree, and TapRooT® Corrective Action Helper Guide was released on May 1, 2015.  This revised 3-piece set is available for purchase to anyone who has attended a TapRooT® course.

Revisions include:

Root Cause Tree: One new root cause and 3 updated root causes.

Root Cause Dictionary: Updates to definitions to cover root cause changes and current industry best practices.

Corrective Action Helper Guide: Updates for new root causes and updated references.

The updated materials are currently available in English only.

Go here to order:

**If you attended a course in 2015, contact for a special discount.

***If you are attending the 2015 Global TapRooT® Summit, you can purchase all at the Summit at a special discount as well! Contact for more information


May 14th, 2015 by


When a major accident happens, look out. The tradition is for “heads to roll.”

That’s right, people get fired.

Who get’s fired? Those that are seen as “part of the problem.”

You need to be part of the solution.


Investigate the incident using the TapRooT® Root Cause Analysis System, find the real, fixable root causes, suggest corrective actions that will prevent the problem from happening again, and be ready to help implement the solutions.

Then you are part of the answer … Not part of the problem.

Or you could just sit around and wait to get fired.

The choice is yours.

Get trained to use TapRooT® root cause analysis to solve problems. See:

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



Grading Your Investigations – Summit Best Practice Session 2 at the 2015 Global TapRooT® Summit in Las Vegas

April 23rd, 2015 by

Mark Paradies is organizing the “Grading Your Investigations” session at the 2015 Global TapRooT® Summit

At this session participants will use an Excel spreadsheet (download your copy below) to grade a typical incident investigation from your facility.

All participants attending this session are asked to bring an investigation report from your facility and the Excel spreadsheet available below preloaded onto a device so that you can participate in the exercise that will teach attendees to grade their company’s investigations using the spreadsheet.


Monday Accident & Lessons Leaned: Learning from a Lack of Accidents

April 20th, 2015 by

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As a stockholder, I was reading The CB&I 2014 Annual Report. The section on “Safety” caught my eye. Here is a quote from that section:

Everything at CB&I begins with safety; it is our most important core value and the foundation for our success. In 2014, our employees maintained a lost-time incident rate of 0.03 for more than 160 million work-hours. This equals one lost-time incident for every 6.2 million hours on the job. These numbers are a testament to our safety record and a reason why we are in the top tier of safest companies in the industry.

CB&I’s lost time incident rate is 50 times better than the industry average (.03 compared to 1.5). That might make you wonder, how do they do that?

Answering that question is learning from a lack of accidents!

Here are a couple of thoughts that I have…

First, when you see this kind of success, you know it is because of management, supervisory, and employee involvement in accomplishing a safe workplace. Everybody has to be involved. There can’t be finger pointing and blame. Everybody has to work together.

Second, I know CB&I is a TapRooT® User. CB&I has trained TapRooT® Investigators to find and fix the root causes of incidents and, thereby, keep major accidents (LTI’s and fatalities) from occurring.

So, congratulations CB&I on your excellent performance! Congratulations on the lives you have saved and the injuries you have avoided!

If you are interested in having industry leading safety performance, perhaps you should get your folks trained to find and fix the root causes of problems by using advanced TapRooT® root cause analysis. Find out about our courses at THIS LINK.

And consider attending the 2015 Global TapRooT® Summit on June 1-5 in Las Vegas. You can:

  • meet industry leaders who are achieving world-class performance
  • benchmark your programs with their programs
  • learn industry leading best practices
  • get motivated to take your safety performance to the next level.

See the 2015 Global TapRooT® Summit schedule at:

Hamburg TapRooT® Course June 15 – 19 … And See the Miniature Wonderland!

April 17th, 2015 by

Attending the 5-Day Advanced Root Cause Analysis Course in Hamburg, Germany will be a great experience because the training is exceptional. But you may also be interested in attending the Miniature Wonderland. Watch the following video for more info …

Hydrocarbon Processing: “True cost of poor quality”

April 2nd, 2015 by

See the article by Heinz Bloch at:

And then attend the Equipment Reliability and Troubleshooting Track at the 2015 Global TapRooT® Summit and hear Heinz speak about the business end of equipment reliability and the foundations of Equifactor®. See the complete Summit schedule at:

TapRooT® Around the World: Lima

March 31st, 2015 by

TapRooT® Instructor, Marco Flores, sent in this great class photo from Lima.

CLICK HERE to view more photos.

We have some awesome training opportunities coming up, including 15 exclusive 2-day courses on every subject from interviewing to stopping human error.  If you missed the recent post, check them out here:

Global TapRooT® Summit Trivia … Can You Answer These Questions?

March 30th, 2015 by


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1. Where was the first TapRooT® Summit (then called the TapRooT® Conference) held?

a) Knoxville

b) Orlando

c) San Antonio

d) Gatlinburg

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2. How many TapRooT® Summits have been held since the first Summit?

a) 18

b) 15

c) 10

d) 6


3. In what year was the first TapRooT® Summit Held?

a) 1988

b) 1994

c) 1997

d) 2000


4. Who was presented with the “Most Beloved Speaker” Award?

a) Ed Skompski

b) Mark Paradies

c) Beverly Chiodo

d) ED Hill

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5. Counting this year, how many times has the Global TapRooT® Summit been held in Las Vegas?

a) 1

b) 3

c) 5

d) 7


6. Where was the largest (by attendance) Global TapRooT® Summit ever held?

a) Austin

b) London

c) Houston

d) Las Vegas


7. How was JR Ewing connected to the Global TapRooT® Summit?

a) He invented it.

b) People from his oil company always attend.

c) He was involved in a TapRooT® investigation.

d) A JR look alike attended the TapRooT® Summit reception in 1998 at the Southfork Ranch.


8. How many Summit Best Practice Tracks are there at this year’s Global TapRoot® Summit?

a) 4

b) 7

c) 9

d) 11


9. You can customize your Summit schedule by picking topics from different Best Practice Tracks.

a) True

b) False


10. Last years Global TapRooT® Summit was held in?

a) Las Vegas

b) Austin

c) Calgary

d) Orlando


Check the comments field below for the answers!

And don’t miss the 2015 Global TapRoot® Summit. For more information see:

What Pre-Summit Course Should You Attend?

March 26th, 2015 by

There are 15 potential Pre-Summit Courses to choose from in June and five of the courses are new. That’s probably why so many people are asking which course would be best for them. Therefore, I thought I’d share my thoughts to help people make the best choice.

First, the 15 Courses are:

Next, let me say that I like all these courses. I’ve hand-picked them to be included before the Summit because I think they will help you solve some of your biggest problems. But I understand that you can only attend one of these courses and that you want to pick the best one, so I’ll offer some advice.


If you haven’t attended a TapRooT® Root Cause Analysis Course before, then you should consider attending the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course. This is the basic/starter TapRooT® Course that all investigators/root cause analysts should take. It will make the Summit much more valuable if you understand how the TapRooT® Root Cause Analysis System works. And it will help you perform much better investigations of safety, quality, and production issues. This course (like all Pre-Summit Courses) is completely guaranteed. We know that you and your management will agree that you will find root causes that you previously would have missed and develop much more effective corrective actions.


Need to improve equipment reliability and apply advanced equipment troubleshooting techniques? Then the Special 2-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis Course is for you. You will learn to apply Heinz Bloch’s advanced troubleshooting techniques to understand how equipment failures occurred. You will then learn to take that information, organize it in a SnapCharT®, identify the Causal Factors, and find each Causal Factors root causes using the TapRooT® Root Cause Tree®. Even equipment troubleshooting experts that have attended this course have commented on the helpfulness of the Heinz Bloch troubleshooting tables and the TapRooT® Root Cause Analysis System.


Want to improve your TapRoot® Skills, especially your ability to identify Causal Factors? Then the Advanced Causal Factor Development Course is for you. Ken Turnbull teaches this course using recent examples of accidents, incidents, and near-misses – some straight from the press. You will get lot’s of hands-on exercise practice and instructor feedback.


Do you need to learn to trend your safety and performance data? Especially data from infrequently occurring accident statistics? Would you like to prove that you have improved performance? Or do you need to mathematically demonstrate that a “trend” really isn’t a trend, but rather, is just normal process variation? That’s what the Advanced Trending Techniques Course is all about. I developed after I saw a client’s advanced trending best practices that blew me away. This was trending that really worked and showed when a trend was real and when it was just normal process variation. It was based on advanced lean/six sigma techniques that were specially modified for low frequency accident data. But the same techniques can be applied to all your data. It truly is a one size fits all trending program that will help your management focus their improvement initiative. In the course you will learn how to draw advanced graphs and practice your skills so that you can apply the techniques to your data back home. The course is taught by Kevin McManus, a quality/safety guru, and I know that you will find it enlightening and very useful.

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The topic of Safety Culture is a hot button in the nuclear, oil, and aviation industry. If you would like to analyze and improve your safety culture, then the TapRooT® Analyzing and Fixing Safety Culture Issues Course is for you. Brian Tink and Brian Tink (Jr & Sr) will show you how to use TapRooT® Tools along with culture analysis tools to analyze and fix safety culture issues. Part of this course is a practice safety culture analysis for your company. If safety culture is a hot button topic at your company, don’t miss this course.

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Interested in risk assessment and management? Want to learn about the latest international standards and how they can help keep your management out of trouble? Then you need to listen to risk management guru Jim Whiting in his course: Risk Assessment and Management Best Practices. Jim shares all the latest risk management techniques and tons of documentation that you will use when you return to work


Interested in applying advanced root cause analysis techniques in a Lean, Six Sigma, or Quality program? Then attend the TapRooT® Quality/Six Sigma/Lean Advanced Root Cause Analysis Training taught by Chris Vallee. Chris is a Six Sigma Black Belt. He will show you how to use TapRooT® Techniques to analyze and fix quality problems, lean waste issues, and problems discovered using Six Sigma techniques.

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Do you provide technical support for the TapRooT® Software? Are you a TapRooT® Software “Power Users” who wants to learn the latest tricks and see the latest software updates? Are you interested in the changes coming in Version 6 of the TapRooT® Software. Are you responsible for setting up the TapRoot® Software and preparing the trending fields and linking the software to other databases? Then you want to attend the Getting the Most from Your TapRooT® Software Course taught by Dan VerLinde, VP for Software Development at SI. You will be amazed how much you learn and how much better your software usage will be.

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What is a hazard? Do you see them before they can cause an accident? If you are interested in Hazard recognition and elimination, then the Hazard Recognition Course is for you. Peter Berkholtz, a TapRoot® Instructor from Australia with 25 years of mining and industrial experience, will teach this practical course. Don’t let hazards sneak up on you. Recognize and eliminate them!


Did you know you could use the TapRooT® System to solve problems before they cause a crisis? If you want to stop problems BEFORE they happen, then the Proactive Use of TapRooT® Course is for you! Dave Janney developed this course after realizing that people would rather stop fatalities before they happen rather than investigate fatalities after they happen. He explains how TapRooT® can be applied to improve auditing, observations and BBS, and pre-job hazard assessments. Learn new ways to apply the TapRoot® System to proactively improve performance at your facility.

And now for the new courses …

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Interviewing and Investigation Basics: We’ve taught this course before but after we had so many positive comments about Barbara Phillips talk on Body language and interviewing at last year’s TapRooT® Summit, we decided to completely revise the course adding new material on interviewing, I think you will find this course to be engaging, useful, practical, and a good use of your time if you are interested in effective cognitive interview and non-verbal techniques and the tools and practices needed to collect information for an effective root cause analysis.


Combating Fatigue: fatigue in the workplace (and while driving) is one of the most frequent, and least investigated, causes of accidents. Studies of actual auto accidents that were video tapped inside the car for later analysis showed that actual fatigue and sleeping was often NEVER reported but was the cause of the accident. What can you do to fight fatigue at your company? Get great ideas from fatigue expert Bill Sirois. Learn to understand the risks of fatigue. Learn the five levels of defense against fatigue. Learn to build and improve a Fatigue Risk Management System (required in several industries). Understand specific methods to handle fatigue in high hazard industries. This course has been completely updated since it was last given before the 2012 Summit and we see it as completely new.

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Understanding and Stopping Human Error: Mark Paradies, President of System Improvements and Joel Haight, Professor of Industrial Engineering at the University of Pittsburg, will bring their considerable knowledge of the practical application of human factors engineering to this newly developed course. The course will cover the human abilities and limitations that lead to human error, how to understand error likely situations and error causing designs, and how to apply error reducing techniques that work and to understand why some error reducing techniques that are frequently suggested are of little practical value. If you are interested in human performance and stopping human error (or at least reducing it as far as practical), then don’t miss this course.

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Root Cause Analysis for Sentinel Events & Healthcare Quality Improvement: Ed Skompski, Vice President at System Improvements, has created a 2-Day TapRooT® Course especially for the healthcare community that focuses on the analysis of the root causes of sentinell events and healthcare quality issues. The course is built around real clinical events and uses the TapRooT® System, a recognized good practice in the healthcare industry and that the terminology is recognized by The Joint Commission.

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Creative Corrective Actions: You may remember this course from the past. Michele Lindsay was a TapRooT® Instructor for over a decade. But she now is a performance improvement coach at a healthcare facility. But this year she will be coming back to the TapRooT® Summit and is presenting a new course on creative corrective actions using Dr. Edward de Bono’s Six Thinking Hats™ techniques.

That’s a lot of training to choose from! But don’t wait too long to register. Seats are limited in these courses and we want you to get your first choice!

Additionally, you get a $200 discount on the training when you also attend the 2015 Global TapRooT® Summit. For more Summit info, see:

And if you have any questions about the Pre-Summit Courses or the Summit, please call us at 865-539-2139. Or CLICK HERE to drop us a note with your question.

Final Exercise at the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in Rome, Italy

March 19th, 2015 by

The students at the Rome 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course show off what they have learned as they analyze an incident from their own company as the final exercise at the course. They then present their work for critique by the rest of the class participants. 

Working on their analysis…

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Presenting …

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If you want to experience the magic of the TaoRooT® Root Cause Analysis System – of how it can help you discover causes that you previously would have missed and develop much more effective corrective actions, then select a course to attend from this upcoming course list:

Or have a course at your facility by contacting us at:

2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in Rome, Italy

March 18th, 2015 by

Here’s the class in Rome…



CLICK HERE to view more photos of this great class!

Do you need to learn advanced root cause analysis techniques that work? See the upcoming class schedule at:

NEW Root Cause Analysis for Sentinel Events & Healthcare Quality Improvement

March 11th, 2015 by

Come learn the TapRooT® process with other healthcare professionals and understand why the TJC recognizes our terminology and understands the quality of what TapRooT® provides in healthcare. Ed Skompski will lead this 2-day course offered June 1 and 2, 2015 in Las Vegas, Nevada — right before the 3-day Global TapRooT® Summit.

Ed Skompski,Vice President
System Improvements

This course provides the basic building blocks of performing both a reactive TapRooT® investigation as well as the use of the TapRooT® tools for Proactive analyses.

With clinical examples and healthcare experts teaching, this learning experience will provide you with the best RCA tools on the market and the knowledge to use them. Tools include:

  • SnapCharT® for organizing and understanding the data you collect;
  • Root Cause Tree® and Dictionary for finding consistent, real root causes that you can communicate to your organization; and
  • Corrective Action Helper® and SMARTER tools to help you define detailed, measurable corrective actions to prevent future events.

All of this adds up to a great training session that you will find to be not only valuable but also practical and useable.

REGISTER for this course and the Improving Healthcare Quality & Patient Safety track at the Summit:

REGISTER for this course alone:

LEARN MORE about the 2015 Global TapRooT® Summit:

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