Root Cause Analysis Blog


Press Release: CSB Announces Upcoming Report on the BP Deepwater Horizon Accident

Posted: April 20th, 2014 in Accidents, Current Events, Investigations


Statement by CSB Chairperson Rafael Moure-Eraso on Fourth Anniversary
of Deepwater Horizon Tragedy in Gulf of Mexico;
CSB Investigation Reports to be Released at June 5th Public Meeting in Houston, Texas

As we approach the fourth anniversary of the April 20, 2010, Deepwater Horizon tragedy and environmental disaster in the Gulf of Mexico, I would like to announce that the comprehensive Chemical Safety Board investigation of the Macondo well blowout is in the final stages of completion and the first two volumes are planned to be released at a public meeting in Houston on June 5.

The death and destruction of that day are seared in our consciousness. The forthcoming CSB investigation report has a singular focus: preventing such an accident from happening again.

Eleven workers lost their lives, many others were injured, and oil and other hydrocarbons flowed uncontrolled out of the well for months after the explosion on the rig, owned and operated by Transocean under contract with BP. The CSB, at the request of Congress, launched an independent investigation with a broad mandate to examine not only the technical reasons that the incident occurred, but also any possible organizational and cultural causal factors, and opportunities for improving regulatory standards and industry practices to promote safe and reliable offshore energy supplies.

While a number of reports have been published on the incident, and changes made within the U.S. offshore regulatory regime, more can be done. On June 5, the CSB will release the first two volumes of our four-volume investigation report, covering technical, regulatory, and organizational issues.

The CSB examines this event from a process safety perspective, integrating fundamental safety concepts, such as the hierarchy of controls, human factors, and inherent safety into the U.S. offshore vernacular. While these concepts are not new in the petrochemical world or in other offshore regions around the globe, they are not as commonplace in the U.S. outer continental shelf.

At the public meeting, investigators will present for board consideration what I believe is a very comprehensive examination of various aspects of the incident.
Going beyond other previously released reports on the accident, the CSB explores issues not fully covered elsewhere, including:

  • The publication of new findings concerning the failures of a key piece of safety equipment—the blowout preventer—that was, and continues to be, relied upon as a final barrier to loss of well control.
  • A comprehensive examination and comparison of the attributes of  regulatory regimes in other parts of the world to that of the existing framework and the safety regulations established in the US offshore since Macondo.
  • In-depth analysis and discussion of needed safety improvements on a number of organizational factors, such as the industry’s approach to risk management and  corporate governance of safety management for major accident prevention, and  workforce involvement through the lifecycle of hazardous operations.

Recommendations will be included in the various volumes of the CSB’s Macondo investigation report.
Volume 1 will recount a summary of events leading up to the Macondo explosions and fire on the rig, providing descriptive information on drilling and well completion activities.

Volume 2 will present several new critical technical findings, with an emphasis on the functioning of the blowout preventer (BOP), a complex subsea system that was intended to help mitigate and prevent a loss of well control. This volume examines the failures of the BOP as a safety-critical piece of equipment and explores deficiencies in the management systems meant to ensure that the BOP was reliable and available as a barrier on April 20, 2010.

Later in the year, the board will consider report Volume 3 which will delve into the role of the regulator in the oversight of the offshore industry. Finally, Volume 4 will explore several organizational and cultural factors that contributed to the incident.

We look forward to presenting this vital information to the public, industry, Congress, and all others interested in fostering safety in the offshore drilling and production industry. 

END STATEMENT  For more information, contact Communications Manager Hillary Cohen, cell 202-446-8094 or Sandy Gilmour, Public Affairs, cell 202-251-5496. 

Friday Joke: Ken Provides Drone Coverage for Summit

Posted: April 18th, 2014 in Jokes, Summit

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Yes, the Global TapRooT® Summit has gone high tech. Here’s a picture of Ken Reed providing arial drone coverage at the 2014 Global TapRooT® Summit. We all felt more secure with Ken keeping an overhead watch!

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

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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

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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!

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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

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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.


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