Root Cause Analysis Blog


Root Cause Analysis Training in the UK – Onsite Course Photos

Posted: July 16th, 2014 in Courses, Pictures

Thanks to Mhorvan Sherret, the TapRooT® Instructor who sent over these photos from a great course he taught in Warwick England June 12-18, 2014. Enjoy!





Contact us for more info on bringing world-class root cause analysis training to your facility.

Career Development: Become Indispensable at Work

Posted: July 16th, 2014 in Career Development, Career Development Tips

Chris Gaborit, Managing Director at The Learning Factor, created this video to inspire us to discover our passion and purpose and to achieve our greatest performance. Invest five minutes of your life to become inspired! reports “The U.S. grid is the worst in the industrialized world (outages are up 285%!)”

Posted: July 15th, 2014 in Current Events, Equipment/Equifactor®

The article starts with …

Power outages in the United States are up an astonishing 285% since 1984. The U.S. ranks last among the top nine Western industrialized nations in the average length of outages. That dismal performance costs American businesses as much as $150 billion every year according to the EIA.

It also has a map of power outage by state:



CLICK HERE to see the whole article.

5 Day TapRooT® Advanced Team Leader Training Course in Niagara Falls, Canada

Posted: July 14th, 2014 in Courses

Steve Swarthout and I are teaching the 5 day course this week in Niagara Falls. Here are some pictures of Steve teaching and students working on their first exercise:







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

Monday Accident & Lessons Learned: UK RAIB Accident Report – Locomotive failure near Winchfield, 23 November 2013

Posted: July 14th, 2014 in Accidents, Current Events, Equipment/Equifactor®, Investigations, Pictures

Screen Shot 2014 06 16 at 12 32 08 PM

The UK RAIB has issued an accident report about the failure of a locomotive near Winchfield, UK. This was a near-miss for a derailment. Here is the Summary:

At about 18:50 hrs on Saturday 23 November 2013, while a steam-hauled passenger train from London Waterloo to Weymouth was approaching Winchfield in Hampshire at about 40 mph (64 km/h), the right-hand connecting rod of the locomotive became detached at its leading end (referred to as the small end), which dropped down onto the track. The driver stopped the train immediately, about one mile (1.6 km) outside Winchfield station. There was some damage to the track, but no-one was hurt. The accident could, in slightly different circumstances, have led to derailment of the train.

Screen Shot 2014 06 16 at 12 34 19 PM

The immediate cause of the accident was that the small end assembly came apart, allowing one end of the connecting rod to drop to the ground. The reasons for this could not be established with certainty because some components could not be found after the accident. It is possible that the gudgeon pin securing nut unwound following breakage of the cotter and previous loosening of the nut. A possible factor is that the design of some components had been modified during the restoration of the locomotive some years earlier, without full consideration of the possible effect of these changes. There were deficiencies in the design and manufacture of the cotter. It is also possible, but less likely, that the securing nut split due to an inherent flaw or fatigue cracking.

RAIB has made four recommendations, directed variously to West Coast Railway Company, the Heritage Railway Association, and the Main Line Steam Locomotive Operators Association. They cover the maintenance arrangements for steam locomotives used on the national network, a review of the design of the small end assembly on the type of locomotive involved in the accident, guidance on the design and manufacture of cotters, and assessment of risk arising from changes to the details of the design of locomotives.

For the complete report, see:


Root Cause Analysis Training in France – Onsite Course Photos

Posted: July 14th, 2014 in Courses, Pictures

We held a great onsite course in Paris, France on June 10-11, 2014. Here are a few photos.





Contact us for more info on bringing world-class root cause analysis training to your facility.

Weekly Wisdom for Root Cause Analysis and Incident Investigation

Posted: July 14th, 2014 in Wisdom Quote



“I suppose it is tempting, if the only tool you have is a hammer; to treat everything as if it were a nail.”

-Abraham Maslow

Monday Motivation: Winston Churchill

Posted: July 14th, 2014 in Pictures


If you’re going through hell keep going. ~ Winston Churchill

Quote from the New Your Times

Posted: July 13th, 2014 in Accidents, Current Events

“These events revealed totally unacceptable behavior. They should never have happened. I’m upset, I’m angry, I’ve lost sleep over this, and I’m working on it until the issue is resolved.”

DR. THOMAS FRIEDEN, director of the Centers for Disease Control and Prevention, which halted shipments of infectious agents from the agency’s labs after accidents with anthrax and flu pathogens.

- – -

What do you think? Time for advanced root cause analysis to get beyond “bad behavior” cause?

Root Cause Analysis Training in Egypt – Onsite Course Photos

Posted: July 11th, 2014 in Courses, Pictures

Thanks, TapRooT® Instructor Harry Thorburn, for these photos and a great onsite TapRooT® Course in Egypt held July 5-10, 2014! DSC03896 DSC03898 DSC03899 DSC03902 DSC03903 DSC03910DSC03882   Contact us for more info on bringing world-class root cause analysis training to your facility.

Root Cause Analysis Tip: 5 Ways to Improve Your Interviews

Posted: July 10th, 2014 in Root Cause Analysis Tips

1) Pick a Good Setting

What is a good setting? Someplace quiet where the interviewee can think without being disturbed. No visual or audible distractions. A place where the interviewee is comfortable and not threatened.

What is a bad setting? The plant manager’s office (threatening). The cafeteria at lunch (distracting). Out in the plant with work going on (distracting).

2) Be Prepared

Perform the interviews in the order to collect the facts first and then look into more complex issues (management system and generic causes). Data collection interviews come before management interviews.

Before any interview, make a list of the topics you hope to cover.

And, of course, be prepared to draw a SnapCharT® during the interview.

3) Don’t Ask Questions

People get the idea that interviews are all about asking questions. Actually, interviews should be about collecting information by getting the interviewee to tell you what they know: Explore his or her recollections (memory).

Often, asking questions hurts this process by interrupting the interviewee’s train of thought. Instead of asking questions, try the cognitive interviewing process taught in the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. We teach people how to combine cognitive interviewing techniques that help people remember what happened with the TapRooT® SnapCharT® technique.

4) Review What Was Collected

When the interview is nearly complete, review what you have learned with the interviewee.

An easy way to do this is to build an informal, draft SnapCharT® during the interview and then review it step by step with the interviewee once the interview is complete.

If you tell the interviewee that you will review what you learned from them at the end of the interview, this often helps the interviewee feel at ease. They can correct any mistakes they make later. Also, they can correct any misconceptions you might have had and fill in additional information that you didn’t pick up which they thought they told you about.

5) Remember to Say Thanks

At the end of an interview, it’s always good to thank the interviewees for their hard work.

But the “thank you” can serve an additional purpose. You can provide the interviewee with your business card and tell them if they remember any additional information after the interview, that they should write it down and then give you a call. Tell them that if they miss you when they call, they should leave a message with all the information they wrote down. 

Throwback Thursday: Blast From The Past

Posted: July 10th, 2014 in Pictures, Summit

Do my eyes deceive me or is that Mark Paradies with a mustache!? Can you believe that this picture is 14 years old?



Pictured Left to Right: Linda Unger, Astronaut Mike Mullane, and Mark Paradies. Astronaut Mike Mullane was a speakers at the 6th Summit in 2000 located in Gatlinburg, TN.

To learn more about who will be speaking at next year’s 2015 Global Summit in Las Vegas, Nevada click here.

Who was your favorite speaker at any Summit you have attended? Please leave comment below.

Root Cause Analysis Tips: 2014 Global TapRooT® Summit Best Practices (US Army Medical Command)

Posted: July 10th, 2014 in Summit, Video

Dana Rocha of US Army Medical Command shared her TapRooT® best practice with us at the 2014 Global TapRooT® Summit, during out Users Share Best Practices session. Watch her video below to learn how she has tailored her TapRooT® investigations so that they are the absolute most thorough they can be:

If you’re at work and don’t have time to watch the video, here’s her tip:

Hello, my name is Dana Rocha, I work for US Army Medical Command. With the help of the navy and the air force we in the army have put together a couple of different documents for people who haven’t been through the training to prepare them for facilitating an RCA as well as sitting on a RCA team. And what we did is we put together a couple of documents for “just in time training” for TapRooT® to help them facilitate and what your roles and responsibilities are on the team. We also put together an RCA trifold and what this is, is a root cause analysis for what event you’re looking at whether its an adverse outcome or sentinel event, near misses or you’re looking at something proactively. It doesn’t matter what you’re looking at, so we use it in different realms. We also put together some checklists. When you do your SnapCharT®, have you considered this? Have you considered that? Check the dates, check the times. Talk to people, and things like that and we found this to be very helpful. And we have done checklists for certain types of events that we find occur more frequently than others. When I say this, don’t freak, but wrong site surgeries do occur, we have retained foreign objects, all kinds of things that do happen, unanticipated deaths, so certain types of events we put together the most common things and asking the questions to make sure that we do a real thorough job when we do the analysis and the investigation so we found that to be very helpful.

Want to learn more about our 2015 TapRooT® Summit in Las Vegas?

Click here:

Root Cause Analysis Training in Kazakhstan – Onsite Course Photos

Posted: July 10th, 2014 in Courses, Pictures

TapRooT® Instructor Harry Thorburn sent over these photos from our recent onsite TapRooT® training course in Kazakhstan. Enjoy!




photo copy


Want to learn our world-class root cause analysis system in the convenience of your own facility? Contact us for more information on on-site courses by clicking here.

Root Cause Analysis Training in Chile – Onsite Course Photos

Posted: July 9th, 2014 in Courses, Pictures

Thanks, TapRooT® instructor Piedad Colmenares, for these great photos of our June 2-6, 2014 onsite course in Punta Arenas, Chile!

ENAP- Punta Arenas - Chile, 5 June 2014.

ENAP- Punta Arenas - Chile, 3 June 2014.

ENAP- Punta Arenas - Chile, 6 June 2014.

Contact us for more info on bringing world-class root cause analysis training to your facility.

Root Cause Analysis Tips: Ever heard of the Dvorak Keyboard?

Posted: July 9th, 2014 in Root Cause Analysis Tips, Software

Have you ever heard of the Dvorak Keyboard?  If not, then you are like most people.

Over the last decade we have helped over 100 customers implement the TapRooT® Web Enterprise Software into their Information Technology networks, and business practices.One thing we’ve learned in that time is that every customer approaches implementation from a different perspective.

Some Companies have their Information Technology department drive the implementation from start to finish; While other Companies have their business users (the Safety people, most commonly) drive the implementation and task the Information Technology with certain objectives.

No matter what the plan of attack is, you need to have a plan (and a champion for that plan) or your implementation will die on the vine, like so many good ideas (including mass adaptation of the Dvorak keyboard) often do.

Below is a document I wrote a few years back to provide to our customers who are undertaking implementation. This document is based on my years of experience implementing software, not just TapRooT®.   What I’m implying is that software implementation has some universal truths that have nothing to do with TapRooT®, they have to do with gaining momentum in implementing a new innovation.

You might even learn a few things about that mysterious Dvorak Keyboard. Click Here To Review this Document.

Accident Causes Red Bull Flood on Florida Highway

Posted: July 9th, 2014 in Accidents, Current Events, Jokes

Screen Shot 2014 07 09 at 10 15 26 AM

Wildlife along I-95 got a caffein overdose when a truck caring Red Bull was involved in an accident. It may be days before they go to sleep and some worried that the animals may take programmers jobs once fully fueled on caffeine. 

See the real story by CLICKING HERE.

Career Development: Lost Respect at Work? by Captain George J Burk

Posted: July 9th, 2014 in Career Development, Career Development Tips

Lost respect at work? A few tips on how to regain it.

Many of us have experienced it. First, it’s the extended lunches. Then, you notice the late arrivals and unexcused tardiness. Next, are the assignments that aren’t finished, not completed to specifications or seem to take longer than usual to complete. When you confront the employee(s) all you hear are the excuses: “I can’t” or “That’s not my job.” That’s your first outward example of a “Wake-Up Call” that you’re a leader who’s losing credibility and respect … and you figure out you need to make some changes … and quick.

“He that is good for making excuses is seldom good for anything else.” Benjamin Franklin

In every situation of which I’m familiar, regardless of the type of organization, when employees respect and trust their leaders and feel that respect and trust in return, you have a highly motivated employee(s) who are more creative and energized people who actually look forward to come to work every day. Every employee I’ve known, myself included, places a high value on a leader they can trust and respect and from who they can learn. That respect and trust is an important, intangible asset. You can’t touch it or taste it but you CAN feel it and you know when it’s there and when it isn’t in the workplace and in the relationship.

“Leadership is one who knows the way, goes the way and shows the way.” John Maxwell

If you need to re-establish yourself as a true leader who your employees and your leadership trust and hold in high esteem, here a few tips to help you reestablish that trust:

Appearances matter. Sometimes dress codes are taken to the extreme. It does seems odd to wear business attire when the company’s culture is T-shirts and jeans. Upgrade you attire to gain respect at work. Develop an approachable presence and internally and externally polished image. Look good … feel good. Don’t over spray with cologne or perfume to mask ‘stuff.’ You know what I’m talkin’ about.

“Appearances rule the world.” Fredrich Schiller

Establish regular feedback sessions with your staff. Leaders who don’t communicate regularly and openly with their staffs miss the opportunity to discover what people really think. Regular feedback sessions not only demonstrate how much you value their opinions, but you’ll also receive an objective, real-time assessment of their strengths and those areas that may need to improve.

“Mentoring is a brain to pick, an ear to listen, and a push in the right direction.” John C. Crosby

Trust demonstrated is trust earned. Empower your staff to own it. Encourage calculated risks and make sure they know you’ll have their back if things don’t turn out as expected. Trust them. Walk-The-Talk.

Watch your “pie hole.”   Words and actions have consequences! If you believe from your intuition and subtle feedback from your staff that you do receive less respect at work, it may because your actions don’t mirror your words and vice versa. Words we use must always be respectful and clean, most discreet when it comes to personal issues and never openly criticize your staff. Praise in public and provide constructive feedback in private … with the door ajar … and with another person in the room with you … it is what it is … lesson learned.

“Good actions give strength to ourselves and inspire good actions in others.” Plato

Know when to be quiet. Emotional tirades earn fear but no respect. Unless you’re one of those (all too many ‘leaders’) who ‘lead’ by fear, tirades may make you feel better but they do little to change the culture at work, except to make it even more toxic. Egg shells are designed to be broken at home, not walked on at work. Address sensitive work issues at a private, one-on-one level not letting your ego show and proudly exclaiming them at meetings and embarrassing the employee(s). The opposite philosophy is always true. When you praise and thank people for a job they’ve done well, always do that in public. Be generous and genuine.

“Nothing strengthens authority more than silence.” Leonardo da Vinci

Share your knowledge. As a leader, you have a great opportunity to be a teacher and mentor. The examples include work directly with a staff member to improve their written and/or oral communications or indirectly, when you lead by example. When you share your information and mentor others, you train and educate the organization’s future leaders.

“The teacher who is indeed wise does not bid you to enter the house of his wisdom but rather leads you to the threshold of your mind.” Khalil Gibran

Suspend assumptions. Place any preconceived ideas you may have aside and really listen to an employee’s proposal with an unbiased perspective. If a conflict does arise, remain objective, stay fair, don’t show favoritism and provide the opportunity for everyone to succeed.

Remain involved. Said another way, get out from behind your desk and walk around the organization. Make the time and take the time to ask questions and then listen. Chat informally at company functions like an office party or get-togethers after work. Get to know your staff and encourage them get to know you. Leave your rank at work.

Be transparent. We’ve heard this many times of late. Change comes in many forms and many ways; some when not expected. When change is on the horizon, remain engaged with your employees and keep them in the loop as much as you can.

“One man’s transparency is another man’s humiliation.” Gerry Adams

Establish the limits (Boundaries). If after your efforts to change the dynamics and your team or staff remain disrespectful, or if one or two apples still spoil the barrel and rather increase their disdain, it’s time for more drastic action. Tell them their behavior is unacceptable and won’t be tolerated. Explain the importance to maintain a civil level or respect and trust in the workplace. Then … document, document, document.  This should be done as a routine practice, anyway. Then, at quarterly, semi-annual and annul performance reviews the behavior was documented and at your disposal.

“The difference between stupidity and genius is that genius has limits.” Albert Einstein

It’s never easy to regain trust and respect at work and with your friends and your family once those values have been lost. A good start is to have a high regard and respect for you … to love yourself but not be in love with yourself. Have that same regard and trust for your team and employees. Want to gain or re-gain trust and respect? Be trustworthy and respectful first. It’s inside out, not outside in … radiate and project what you want and expect outwards. This will most often encourage them to reciprocate.

“Men are respectable only as they are respected.” Ralph Waldo Emerson


This article was submitted by “Captain George” J Burk, USAF (Ret), Scottsdale, Contact:

Press Release from the UK RAIB: Accident to a track worker near Redhill, 24 June 2014

Posted: July 8th, 2014 in Accidents, Current Events, Investigations, Pictures

NewImageSite of the accident

 RAIB is investigating an accident to a track worker who was supervising a gang carrying out track maintenance work near Redhill in Surrey. The accident occurred at about 10:40 hrs on 24 June 2014. The track worker was struck by a passenger train and suffered serious injuries.

The injured person was with a gang of eleven people engaged in undertaking repairs to the Up Quarry line between Redhill Tunnel and Quarry Tunnel. The train, a passenger service from Gatwick Airport to London Victoria, was travelling at about 80 mph (129 km/h).

RAIB’s investigation will consider the sequence of events and factors that may have led to the accident, and identify any safety lessons.

RAIB’s investigation is independent of any investigations by the safety authority or the police. RAIB will publish its findings at the conclusion of the investigation. This report will be available on the RAIB website.

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