Root Cause Analysis Blog


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

Posted: April 16th, 2014 in Root Cause Analysis Tips, TapRooT, Video

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


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

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

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


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

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


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

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


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

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

How Far Away is Death?

Posted: April 15th, 2014 in Video

Doesn’t take a very big mistake by the excavator operator to make this a fatality…

Weekly Wisdom for Quality & Root Cause Analysis

Posted: April 15th, 2014 in Wisdom Quote


“One cannot develop taste from what is of average quality but only from the very best.”
- Johann Wolfgang Von Goethe

Root Cause Analysis Training in the United Kingdom – Scotland TapRooT® Course Photos

Posted: April 15th, 2014 in Courses, Pictures

TapRooT® Instructor Harry Thorburn shared these photos from our March 31-April 4, 2014 5-Day TapRooT® Root Cause Analysis Team Leader Training in Aberdeen, Scotland. Enjoy!

Interested in learning more or attending a 5-Day TapRooT® Course? Click here to learn more about our 5-Day Course.





2 Day TapRooT® Incident Investigation and Root Cause Analysis Course in Philadelphia

Posted: April 14th, 2014 in Courses

I am in Philadelphia this week teaching the 2 day course. Here are some pictures of day one activities:






Why not join us for the next course? You can see the schedule and register HERE

2014 Global TapRooT® Summit Day 3 – Annual Summit Charity Golf Tournament

Posted: April 14th, 2014 in Courses, Pictures, Summit

We really enjoyed the gorgeous weather and fabulous course at the Horseshoe Bay Resort on Friday April 11th, 2014. Between your generous donations and System Improvements’ matching, we raised over $4,700 for Oasis of Love Women’s Shelter in Clinton, Tennessee. A big thank you to everyone who contributed to this wonderful charity.
Here are a few photos:

The golf video/photo team.











And the winners:

John Malloy – Longest Drive on #4 and Closest to the Pin on #8

Kim Page – Longest Drive #7

Robert Pohl – Longest Drive on #10

Steve Raycraft – Longest Drive on #11

Michael Podgorny – Closest to the Pin on #3

Lindsay Kemp – Closest to the Pin on #12

Scott Robinson – Closest to the Pin on #17


Ken Scott’s team of Buck Griffith, Loren Stagner, and Paul Larson was the winner again this year. Since this was our last golf tournament for a while, we were glad it was one of the best!

Monday Accident & Lessons Learned: Was the Baker Report a Failure?

Posted: April 14th, 2014 in Accidents, Performance Improvement

Screen Shot 2014 03 24 at 9 39 02 AM


For those that have followed BP’s accidents (the explosion at Texas City and the blowout and explosion of the Macondo well to name the most prominent), the Baker Report is a famous independent review of the failure of process safety at BP.

I was reading a discussion about process safety and someone brought up the Baker Report as an excellent source for process safety knowledge. That got me thinking, “Was the Baker Report successful?”

The initial Panel Statement at the start of the report includes this quote:

“In the aftermath of the accident, BP followed the recommendation of the U. S. Chemical Safety and Hazard Investigation Board and formed this independent panel to conduct a thorough review of the company’s corporate safety culture, safety management systems, and corporate safety oversight at its U.S. refineries. We issue our findings and make specific and extensive recommendations. If implemented and sustained, these recommendations can significantly improve BP’s process safety performance.”

I believe the Deepwater Horizon/Macondo accident provides evidence that BP as a corporation either didn’t learn the lessons of the report or didn’t implement the fixes across the corporation, or that the report was not successful in highlighting areas to be changed and getting management’s attention.

What do you think?

Was the report successful? Did it cause change and help BP have an improved process safety culture?

Or did the report fail to cause change across the company?

And if it failed, why did it fail?

Let me know your ideas by leaving your comments by clicking on the comments link below.

Monday Motivation: Do You Have the Passion to Keep Going?

Posted: April 14th, 2014 in Performance Improvement, Pictures


Steve Jobs:

You have to be burning with an idea, or a problem, or a wrong that you want to right. If you’re not passionate enough from the start, you’ll never stick it out.

Short Note About the Summit

Posted: April 11th, 2014 in Pictures, Summit

IMG 2697

Best Summit EVER!

Had a great time and learned great new best practices.

Had people tell me that they often attend conferences and this was the best one they have ever attended BY FAR!

Another person told me that they took away practical things to improve performance from EVERY session and they were so excited that they texted, e-mailed, and called people back at work to get things implemented BEFORE they got back.

I post more next week … stay tuned!

IMG 2717

LIVE from Texas: The 2014 Global TapRooT® Summit! Day 3

Posted: April 11th, 2014 in Pictures, Summit

This Summit has been a great one. We’ve enjoyed sunny Texas weather, gorgeous LBJ Lake sunsets, and a truly motivational time of learning root cause best practices and meeting new colleagues.

This morning, our own Barbara Phillips shared interviewing tips for reading non-verbal behavior. I never knew there were so many little body language signals to read and find out what people are really communicating! Baarbara also received an award for being a favorite speaker here at the TapRooT® Summit.





Then we gathered together in groups for our Planning Your Improvements sessions, and discussed the best practices we’ll bring back home to improve our workplaces.


And we ended our day and our 2014 TapRooT® Summit with a keynote address from Rocky Beleier, Vietnam Veteran and former Pittsburgh Steeler. What an honor to meet him and an inspiration to hear his story and what he learned through life’s challenges.



Now that the day’s done, we’re ready for more fun! We’re headed to our annual Summit Charity Golf Tournament. Join us tomorrow for photos of that!

What was your favorite part of the Summit experience? Share in the comments below!

Friday Joke: New Type of Submarine

Posted: April 11th, 2014 in Accidents, Jokes, Pictures

 Hphotos-Ash3 1175575 296035567204633 662748754 N

Doesn’t it need a snorkel?

LIVE from Texas: The 2014 Global TapRooT® Summit! Day 2

Posted: April 10th, 2014 in Pictures, Summit

Day 2 of the 2014 Global TapRooT® Summit was just as great as the first. Mark Paradies, TapRooT® Co-Creator and System Improvements President, discussed how we can perform world class performance improvement in his keynote address.



Then Dan Verlinde showed us What’s New in the TapRooT Software. He asked his over 150 attendees to clap when he showed an improvement they liked, so he could get immediate feedback. Suffice it to say that he received a lot of applause today!



Alan Smith, Alan Scott, and Harry Thorburn shared a sobering and captivating session called Infamous Accidents, in which they discussed the Piper Alpha and Titanic disasters and potential root causes and ways these events could have been prevented. Alan Scott shared his personal experience assisting in the Piper Alpha investigation. It was powerful and fascinating.


Our day rounded out with a passionate keynote address from Edwin G. Foulke, Jr., Former Assistant Secretary of Labor for OSHA. He let us in on OSHA’s future sweeping workplace safety changes. My favorite quote from him was, “You have to have safety before you can have efficiency, productivity, and quality.”


Join us tomorrow for a recap of our third and final day of the 2014 Global TapRooT® Summit!

Did you attend the Summit? What was your favorite experience of the day? Please share in the comments below!

LIVE from Texas: The 2014 Global TapRooT® Summit! Day 1 – Reception

Posted: April 10th, 2014 in Pictures, Summit

Last night’s Summit Reception was a blast! The Yacht Club at the Horseshoe Bay Resort hosted us, and served delicious appetizers and drinks in the beautiful Texas evening. Carl Dixon of The Guess Who spent hours jamming on his guitar and making our evening unforgettable. We so enjoyed networking and having fun with you last night!








2014 Pre-Summit Courses Start Off With A Bang!

Posted: April 8th, 2014 in Courses, Pictures

Our TapRooT(R) Pre-Summit courses are going great! Attendees are using team exercises to build root cause analysis expertise. The gorgeous weather doesn’t hurt either! We also celebrated Summit Videographer Josh Unger’s birthday yesterday – what a treat!



How Far Away is Death?

Posted: April 8th, 2014 in Accidents, Human Performance, Video

Not too far on this day in 1983…

Weekly Wisdom for Quality & Root Cause Analysis

Posted: April 8th, 2014 in Wisdom Quote


“It is easier to do a job right than to explain why you didn’t.” – Martin Van Buren

Root Cause Analysis Training in Colombia – Course Photos

Posted: April 8th, 2014 in Courses, Pictures

Thank you to TapRooT® Course Planner Diana Munevar for a great onsite TapRooT® Root Cause Analysis Course and for these photos!

Click here to learn more about our South America courses.








WhoDunIt? Things Are Heating Up Pre-Summit

Posted: April 7th, 2014 in Summit

If you look closely, there is not only an outline of a body on the floor but blood on the corner of the striped couch. Looks like a murder mystery, but it is part of the 2-Day Pre-Summit TapRooT® Evidence Collection Course.


Pictures from the TapRooT® Pre-Summit Courses

Posted: April 7th, 2014 in Courses, Pictures, TapRooT

What does it look like attending one of the 13 pre-Summit courses? Have a look at these pictures. People are actively learning…

IMG 2657

IMG 2659

IMG 2661

IMG 2662

IMG 2664

IMG 2666

IMG 2671

IMG 2672

IMG 2677

IMG 2679

IMG 2685

IMG 2687

IMG 2690





Monday Motivation: Harriet Tubman

Posted: April 7th, 2014 in Performance Improvement, Pictures



Harriet Tubman:

Every great dream begins with a dreamer. Always remember, you have within you the strength, the patience, and the passion to reach for the stars to change the world.

Monday Accident & Lessons Learned: Incident Report from the UK Rail Accident Investigation Branch: Tram running with doors open on London Tramlink, Croydon

Posted: April 7th, 2014 in Accidents, Current Events, Human Performance, Investigations, Pictures

Screen Shot 2014 03 06 at 6 23 50 PM

There were eight recommendations made by the UK RAIB. here’s a summary of the investigation:

On Saturday 13 April 2013 between 17:33 and 17:38 hrs, a tram travelling from West Croydon to Beckenham Junction, on the London Tramlink system, departed from Lebanon Road and Sandilands tram stops with all of its doors open on the left-hand side. Some of the doors closed automatically during the journey, but one set of doors remained open throughout the incident. The incident ended when a controller monitoring the tram on CCTV noticed that it had departed from Sandilands withits doors open, and arranged for the tram to be stopped. Although there were no casualties, there was potential for serious injury.

The tram was able to move with its doors open because a fault override switch, which disables safety systems such as the door-traction interlock, had been inadvertently operated by the driver while trying to resolve a fault with the tram. The driver didnot close and check the doors before departing from Lebanon Road and Sandilands partly because he was distracted from dealing with the fault, and partly because he did not believe that the tram could be moved with any of its doors open. The design of controls and displays in the driving cab contributed to the driver’s inadvertent operation of the fault override switch. Furthermore, breakdowns in communication between the driver and the passengers, and between the driver and the controller, meant that neither the driver nor the controller were aware of the problem until after the tram left Sandilands.

The RAIB has made eight recommendations. Four of these are to Tram Operations Ltd, aimed at improving the design of tram controls and displays, as well astraining of staff on, and processes for, fault handling and communications. Two recommendations have been made to London Tramlink, one (in consultation with Tram Operations Ltd) relating to improving cab displays and labelling and one on enhancing the quality of the radio system on the network. One recommendation is made to all UK tram operators concerning the accidental operation of safety override switches. The remaining recommendation is to the Office of Rail Regulation regarding the provision of guidance on ergonomics principles for cab interface design.


For the complete report, see:

Connect with Us

Filter News

Search News


Barb PhillipsBarb Phillips
Editorial Director
Chris ValleeChris Vallee
Human Factors & Six Sigma
Dan VerlindeDan Verlinde
Information Technology
Dave JanneyDave Janney
Safety & Quality
Ed SkompskiEd Skompski
Medical Issues
Ken ReedKen Reed
Linda UngerLinda Unger
Vice President
Mark ParadiesMark Paradies
Creator of TapRooT®
Megan CraigMegan Craig
Media Specialist
Steve RaycraftSteve Raycraft
Technical Support

Success Stories

Our challenge was to further improve the medication administration process at our facility by proactively…

Jackson County Memorial Hospital

In 1995, BellSouth Telecommunications noticed an increase in the number of service interruptions or outages…

Bell South
Contact Us