Root Cause Analysis Blog


Root Cause Analysis Tip: Investigating a Procedure Problem

Posted: September 28th, 2016 in Root Cause Analysis Tips

TapRooT® Users … What do you do when you think there may be a problem with a procedure that contributed to a Causal Factor that led to an Incident?

Here’s a tip from the soon to be published book: TapRooT® Root Cause Analysis for Major Investigations.

To investigate problems in the Procedures Basic Cause Category:

  1. Get an unused copy of the procedure.
  2. Get the completed, signed-off or checked-off procedure (if sign-off/check-off is required).
  3. Get any reference material/documentation.
  4. Was procedure used?
  5. Was it signed-off properly?
  6. Verify technical accuracy of the procedure (table-top review).
  7. Verify usability of the procedure by performing a field walk-through.(Consider performing a Critical Human Action Profile, Appendix F,and reviewing potential human factors problems at the same time.)
  8. If problems are found, consider looking for generic causes in the procedure writing and review system.

That’s the start of the guidance provided in the book that will be published in November. Watch for our notice about the release and get your copy for guidance investigating all of the Basic Cause Categories on the back side of the TapRooT® Root Cause Tree®.

My favorite procedure related story was and investigation where the team doing the investigation said that the person who was injured was using a procedure. I asked to see it. They said:

You want to see the procedure?

I said “Yes.”

They sent someone off to get it.

They came back with a brown paper grocery bag.

They handed it to me.

I said, “What’s this?”

They said, “the procedure.”

I looked in the bag. There was nothing inside.

They said, “No look on the outside of the bag.”

There were hand written notes on the outside of the bag. Mainly equipment part numbers. That was …

The Procedure.

ALWAYS ask for a procedure when someone says that a procedure was used. You might get a good laugh too!

Users Share Best Practices: Adding a Union Rep to an Investigation

Posted: September 28th, 2016 in Root Cause Analysis Tips, Summit, Summit Videos, Video Depot

Our 2016 Global TapRooT® Summit was a great success this year! Our attendees helped one another by sharing some of their best practices. Here is Don Marsh discussing his best practice of adding a union rep to each investigation.

(Click post title if video is not displaying.)

Weekly Wisdom: We must do.

Posted: September 27th, 2016 in Wisdom Quote

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“I have been impressed with the urgency of doing. Knowing is not enough; we must apply. Being willing is not enough; we must do.”- Leonardo da Vinci

Monday Accident & Lessons Learned: Fatigue

Posted: September 26th, 2016 in Accidents, Current Events, Investigations

Here is a link (click of picture below) to a Callback publication about accidents and Fatigue …

Fatigue Callback

Here is a quote:

“The NTSB 2016 “Most Wanted List” of Transportation Safety Recommendations leads with, ‘Reduce Fatigue-Related Accidents.” It states, “Human fatigue is a serious issue affecting the safety of the traveling public in all modes of transportation.’”

Friday Joke: Labels NI

Posted: September 23rd, 2016 in Jokes

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Technically Speaking – Helpdesk Humor

Posted: September 22nd, 2016 in Software, Technical Support, Technically Speaking


Root Cause: No Training or Continuing Training NI? If you need to brush up on your understanding of Root Cause Analysis or would like to get more training click HERE to find a course near you.

Technically Speaking is a weekly series that highlights our TapRooT® VI software and occasionally includes a little Help Desk humor.
Remember, just because it’s technical, doesn’t mean it has to be complicated!

We’re going to St. John’s!

Posted: September 22nd, 2016 in Courses, Local Attractions

We can’t wait to head to St. John’s, Newfoundland for our 5-Day Advanced Root Cause Analysis and Team Leader Training course November 14-18. Not only will you improve your root cause analysis techniques and bring home valuable knowledge to your company, but you’ll also get the chance to visit this beautiful, historic city. St. John’s is considered to be the oldest English-founded city in North America. It’s English culture, beautiful harbour and colorful architecture gives it a distinct & unique personality.


RocketFood: This quaint bakery and fresh food cafe has been recognized on the Food Network and several international magazines. It must be delicious!

Raymond’s: If you’re interested in a more gourmet, upscale restaurant then Raymond’s is for you.

ONE11 Chophouse: A great steak isn’t all this highly-rated chophouse has to offer. The warm, fine dining experience is one of the best around.


Newman Wine Vaults: Enjoy a variety of fresh wine at one of Newman’s Wine Vaults.

East Coast Trail: Would you consider yourself an outdoor enthusiast? Take a hike on the East Coast Trail and see views of St. John’s that you can’t see anywhere else.

Commissariat House: Experience the 19th Century British power struggle through a well-done interactive exhibit at the Commissariat House.


Interested in other TapRooT® Public Courses around the world? Click here.

Interested in an Onsite Course for your teams? Click here.

What does a bad day look like?

Posted: September 21st, 2016 in Pictures


Enter Our Trivia Contest!

Posted: September 21st, 2016 in Contest


Our next contest is some trivia about the new TapRooT® VI software! Test your knowledge of just a few of the newest features offered in this incredible software.

Follow the link to the trivia, answer and enter to win. You could be the lucky winner!



Choose or (Always) Lose

Posted: September 20th, 2016 in Career Development, Career Development Tips

The following article was reprinted with permission from the author, Captain George Burk, USAF (Ret), Plane crash, burn survivor, motivational speaker, author, writer. Visit his website at or contact Captain Burk at

There are times when all of us find it difficult to make a decision. I know I have! Sometimes, the best decision is the one we didn’t make and time and outcome(s) showed we were correct. There are legitimate reasons to not make a decision. Some of these reasons have to do with time, resources, lack of adequate information and or our desire and the will to take some type of action.

That said, psychologist Susan Jeffries tells a story that shows the inherent risk involved when people won’t or, choose not to, make a decision.

Once upon a time, she says, there was a donkey that stumbled upon two bales of hay. Both looked good and had a pleasing, pastoral bouquet. The donkey stood before the hay for hours, trying to pick which one the donkey would consume.

In the meantime, the donkey grew hungrier. Afraid he’d miss out on the best pile of greens, he did nothing. Just like the donkey, when people fail to choose, they get stuck.

“The irony of course, is that by not choosing, we are choosing—to starve,” Jeffries said. “We are choosing to deprive ourselves of what makes life a delicious feast.”

Jeffers, author of “Feel the Fear and Do It Anyway,” explains why people find it difficult to make a decision. “Our need to be perfect and our need to control the outcome of events work together to keep us petrified when we think about making a change or attempting a new challenge,” she said. “The inability or unwillingness to make a decision leads to a real or imagined loss of self-esteem and self-worth, a lack of progress and growth and ultimately mediocrity.” So…lead, follow or get the ‘heck’ out of the way.

“Middleness is the very enemy of the bold.”
Charles Krauthammer, writer

To break that paradigm, Jeffers recommends turning away from no-win thinking and changing to a no-lose way of thinking.

Jeffers suggests to affirm: “I can’t lose—regardless of the outcomes of my decision.” As I’ve said many times before, learn to fill yourself with positive affirmations. Change your internal script from negative thinking to a more positive view— “I can’t” to “I will.” “I’m not a good speaker” to, “I will become a great speaker.” The examples are personal and professional and are endless.

Look at the world as a great place for opportunity and growth, and you will look forward to the opportunities for learning and growing that either path you choose will give you. Think of your glass of life as being half-full, not half-empty.

“One can never consent to creep when one feels an impulse to soar.”
Helen Keller, writer

Even some of life’s most stressful events and we all have them —job loss, financial challenges, divorce, non-life threatening illness or worse—being burned and severely injured, for instance—have a way of leveling the playing field and giving us plenty of material that can provide us with internal fuel later, when we step-out to accomplish our next dream (vision) and goal. This can occur in the form of more contacts that expand our network or an important personal or business lesson.

“Traditionally, opportunities in life are thought of as relating to money, status and the visible signs of ‘success,’” she said. “Think of opportunities in a completely different light.” Through my personal life experiences, I’ve learned there’s nothing worse than an amputated spirit and without hope, one’s success and survival is significantly diminished if not lost.

“Death is not the greatest loss in life. The greatest loss in life is what lies inside us while we live.”
Norman Cousins, writer

Now, after you’ve refined and tweaked your thinking, begin to use the doldrums-busting steps below:

Do your homework. Securing relevant information is an important first step of the decision-making process and can keep you moving forward. “Don’t be afraid to approach the specific people involved relative to the decision to be made,” Jeffers said. Acknowledge what you don’t know. Seek out those who can help you learn. Enhance the positives and make the negatives disappear or at least, less apparent.

“Those who cannot remember the past are condemned to repeat it.”
George Santana, philosopher

Set your priorities. Start by learning and focusing on the here and now. The issues that drive you today may well be a different color or originate from a different source than those you had last year. Goals are dynamic and, if developed properly, will change as you make progress. “You have to keep reassessing them,” Jeffers said.

“You only get back what you expect, and if you start low you’ll end low.”
Colin Powell, general and secretary of state

Listen to your gut speak. Quite often, your intuition, your sub-conscious mind provides messages as to what choice is best to make at a specific time. There have been many times in my life when my gut instinct
told me the choice I wanted to make was the right one. But, for any number of reasons, I rationalized that choice away and made another choice. Later, to my dismay, I discovered that my first, intuitive choice would have been the best one for me. What that taught me is to trust my intuition, my “gut” more often and go with my first choice and then not look over my shoulder.

“Don’t look over your shoulder. Someone may be gaining.”
Satchel Paige, professional baseball player

Don’t worry. Be happy. Leave the gnashing of teeth and the wailing about how life’s unfair, the stomping of feet and the verbal and non-verbal “woe is me” to others. Learn to trust in your ability to handle whatever life happens to throw your way. When life gives you a lemon, you have a choice. You can become a sourpuss or you can make lemonade. Self-made lemonade tastes great!!

“It is pretty hard to tell what does bring happiness; poverty and money have both failed.”
Kim Hubbard, humorist

Begin to think as if you’re a lifetime student (which we are) at a college or university. Call it the “University of Life,” where every day’s an adventure and every meal’s a banquet. The University of Life is where you eagerly anticipate the new people you’ll meet, the challenges you’ll face and how those challenges will pull you—or drag you—to change into the person you really want and can become. Each experience, whether positive or negative, is a valuable learning tool, each are “Teachable Moments.”

“If a window of opportunity appears, don’t pull down the shade.”
Tom Peters, business coach

The difference between a winner and a whiner is their attitude and a two letters. How well do you ‘spell’? EH?

Weekly Wisdom: Find the meaning in life.

Posted: September 20th, 2016 in Wisdom Quote

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“Challenges are what make life interesting and overcoming them is what makes life meaningful.” -Joshua J. Marine

And the winner is …

Posted: September 19th, 2016 in Contest

The winner of the most recent caption contest is (drum roll please) …

Barry Eichler

with his caption “Cutting Staff for Cost Savings.”

Congratulations Barry!

We had a great time judging this contest and are amazed at how clever you all are.  Check back soon for a new contest!!!

Monday Accident & Lessons Learned: Overspeed at Fletton Junction

Posted: September 19th, 2016 in Accidents, Current Events, Human Performance, Investigations, Pictures

This incident notice is from the UK Rail Investigation Branch about an overspeed incident at Fletton Junction, Peterborough on 11 September 2015.

At around 17:11 hrs on 11 September 2015, the 14:25 hrs Virgin Trains East Coast passenger train service from Newcastle to London King’s Cross passed through Fletton Junction, near Peterborough at 51 mph (82 km/h) around twice the permitted speed of 25 mph (40 km/h). This caused the carriages to lurch sideways resulting in minor injuries to three members of staff and one passenger.

It is likely that the train driver had forgotten about the presence of the speed restriction because he was distracted and fatigued due to issues related to his family. Lineside signs and in-cab warnings may have contributed to him not responding appropriately as he approached the speed restriction and engineering controls did not prevent the overspeeding. Neither Virgin Trains East Coast, nor the driver, had realised that family-related distraction and fatigue were likely to be affecting the safety of his driving. Virgin Trains East Coast route risk assessment had not recognised the overspeeding risks particular to Fletton Junction and Network Rail had not identified that a speed limit sign at the start of the speed restriction was smaller than required by its standards.

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The incident could have had more serious consequences if the train had derailed or overturned. The risk of this was present because the track layout was designed for a maximum speed of 27 mph (43 km/h).
As a consequence of this investigation, RAIB has made five recommendations. Two addressed to Virgin Trains East Coast relate to enhancing the management of safety critical staff with problems related to their home life, and considering such issues during the investigation of unsafe events.

A recommendation addressed to Virgin Trains East Coast and an associated recommendation addressed to Network Rail relate to assessing and mitigating risks at speed restrictions.

A further recommendation to Network Rail relates to replacement of operational signage when this is non-compliant with relevant standards.

RAIB report also includes learning points relating to managing personal problems that could affect the safety performance of drivers. A further learning point, arising because of a delay in reporting the incident, stresses the importance of drivers promptly reporting incidents which could have caused track damage. A final learning point encourages a full understanding of the effectiveness of safety mitigation provided by infrastructure and signalling equipment.

For more information see:


Friday Joke: Labels NI

Posted: September 16th, 2016 in Jokes

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Root Cause Analysis Tip: Going Beyond Root Cause Analysis to Fix Company-Wide Problems

Posted: September 15th, 2016 in Root Cause Analysis Tips

All TapRooT® Users have experienced the effectiveness of using the Root Cause Tree® and Dictionary to find the specific root causes of a particular incident. They fix these causes and eliminate (or at least reduce) the chance of identical repeat incidents.

Here is the question …

Can we do more?

The answer is … YES!

In the TapRooT® System, the next step after determining the specific root causes is to identify the Generic root causes.

What is a Generic root cause?

Generic Cause
The systemic cause that allows a root cause to exist.
Fixing the Generic Cause eliminates whole classes of specific root causes.

These are the causes that are present across the organization. Think of it as looking at the big picture.

If you have a problem with a procedure, what in the procedure writing system is allowing the problem to exist?

If you have a training issue, what in the way you develop and provide training or test people for proficiency is causing problems?

Get the idea?

Sometimes using the Corrective Action Helper® Guide can help you identify Generic Causes.

To do this we use this three step process:

For each root cause identified using the Root Cause Tree® Diagram:

  1. Review the “Ideas for Generic Problems” section of the Corrective Action Helper® Guide for the root causes you have identified.
  2. Ask: “Does the same problem exist in more places?”
  3. Ask: “What in the system is causing this Generic Cause to exist?”

Once you identify the systemic cause (or causes), you fix them!

You then need to do a system wide evaluation to correct all the problems that exist from the old system by implementing the changes recommended for the new system.

Once you complete these corrective actions, you have fixed the immediate issues and made sure that you won’t create new issues in the future.

That’s going beyond simple root cause analysis.


TapRooT® Around the World: Montreal, Quebec, Canada

Posted: September 15th, 2016 in Courses, Local Attractions


TapRooT® is coming to Montreal! Our essential 2-Day TapRooT® Root Cause Analysis public course will be offered October 24-25. In this course, you’ll learn how our robust system will improve every step of your investigations.

Montreal prides itself on preserving their old Europe feel within such a large, contemporary city. Buildings such as Basilique Notre Dame and Stade Olympique are within close proximity to each other, but they couldn’t be more different in architectural design. Join TapRooT® in October and find many other examples of such diverse and unique design.


Le Robin Square: A fun twist on classic favorites like hotdogs, BLTs and french fries.

Damas Restaurant: Middle Eastern food is a delicacy that Montreal chefs have mastered and shared within North American cultures.

Breizh Cafe: Enjoy a cozy cup of fresh coffee along with a variety of homemade desserts and crepes, a traditional French favorite.


Notre-Dame Basilica: This historical monument is a treasure in Montreal that any tourist would appreciate.

Whiskey Café: Walk back in time to this 1930’s themed bar filled with whiskey, wine & cigars galore.

Montreal Museum of Fine Art: Filled with Contemporary art, graphic design, Canadian artists, and many more, this art museum is for any art enthusiast.

Ready to REGISTER NOW? Follow this link to our registration page.

Technically Speaking – Customizing TapRooT® VI for Your Company

Posted: September 15th, 2016 in Software, Software Updates, Technical Support, Technically Speaking

TapRooT® VI lets you skin your reports and home page with your company logo, including building reports, lists,  and tabs that match your company standards.


report skin

Add your company logo under ADMIN > ORGANIZATIONAL PROFILE and upload the image file. (This is where you upload the image for reports as well)

Build lists, fields, and tabs that apply directly to your company.  Let your company’s demands unlock TapRooT® VI’s potential.


custom tab sample

Add your lists & fields to tabs to revolutionize how you perform investigations.


These features are waiting for everyone, but you can go even further with TapRooT® VI Enterprise.

Utilize the TapRooT® VI Enterprise to share report templates, manage custom tabs & lists, and trend across your solution with all your co-workers.


Contact us about getting TapRooT® VI Enterprise for your company!

Technically Speaking is a weekly series that highlights various aspects of the TapRooT® VI software and occasionally includes a little Help Desk humor.

Remember, just because it’s technical, doesn’t mean it has to be complicated!

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