Root Cause Analysis Blog


TapRooT® Public Courses in Oceania & Asia

Posted: May 5th, 2016 in Courses


Perth, Australia

Upcoming TapRooT® Public Courses:

Queensland Australia: Gladstone, 2-Day, May 23 | Emerald, 5-Day, July 4 | Brisbane, 2-Day,  July 26North Australia: Darwin, 2-Day, June 27 West Australia: Perth, 2-Day, June 23 | Karratha, 2-Day, July 4 | Perth, 2-Day, July 7 | Perth, 5-Day, July 18 South Australia: Sydney, 2-Day, June 20 | Adelaide, 5-Day, July 11Victoria Australia:  Melbourne, 5-Day, June 6 | Melbourne, 2-Day, July 19New Zealand: New Plymouth, 5-Day, June 13

Want a course in your region? Inquire about an Onsite Course here.

For more information regarding our public courses around the world, click here.

REGISTER FOR THE 2016 TapRooT® Summit NOW.

Root Cause Analysis Tip: Save Time and Effort

Posted: May 4th, 2016 in Current Events, Performance Improvement, Pictures, Root Cause Analysis Tips, TapRooT, Training

The Nuclear Energy Institute published a white paper titled:

Reduce Cumulative Impact From the Corrective Action Program

To summarize what is said, the nuclear industry went overboard putting everything including the kitchen sink into their Corrective Action Program, made things too complex, and tried to fix things that should never have been investigated. 

How far overboard did they go? Well, in some cases if you were late to training, a condition report was filed.

For many years we’ve been preaching to our nuclear industry clients to TARGET root cause analysis to actual incidents that could cause real safety or process safety consequences worth stopping. We actually recommend expanding the number of real root cause analyses performed while simplifying the way that root cause analyses were conducted.

Also, we recommended STOPPING wasting time performing worthless apparent cause analyses and generating time wasting corrective actions for problems that really didn’t deserve a fix. They should just be categorized and trended (see out Trending Course if you need to learn more about real trending).

We also wrote a whole new book to help simplify the root cause analysis of low-to-medium risk incidents. It is titled:

Using the Essential TapRooT® Techniquesto Investigate Low-to-Medium Risk Incidents


 Just published this year, this book is now the basis for our 2-Day TapRooT® Root Cause Analysis Course and starting on Thursday will be the standard book in out public 2-Day TapRooT® Courses.

Those who have read the book say that it makes TapRooT® MUCH EASIER for simple investigations. It keeps the advantages of the complete TapRooT® System without the complexity needed for major investigations. 

What’s in the new book? Here’s the Table of Contents:

Chapter 1: When is a Basic Investigation Good Enough?

Chapter 2: How to Investigate a Fairly Simple Problem Using the Basic Tools of the TapRooT® Root Cause Analysis System

  • Find Out What Happened & Draw a SnapCharT®
  • Decision: Stop or More to Learn?
  • Find Causal Factors Using Safeguard Analysis
  • Find Root Causes Using the Root Cause Tree® Diagram
  • Develop Fixes Using the Corrective Action Helper Module
  • Optional Step: Find and Fix Generic Causes
  • What is Left Out of a Basic Investigation to Make it Easy?

Chapter 3: Comparing the Results of a 5-Why Investigation to a Basic TapRooT® Investigation

Appendix A: Quick Reference: How to Perform a Basic TapRooT® Investigation

The TapRooT® Process for simple incidents is just 5 steps and is covered in 50 pages in the book.

If you are looking for a robust techniques that is usable on your simple incidents and for major investigations, LOOK NO FURTHER. The TapRooT® System is the answer.

If you are in the nuclear industry, use TapRooT® to simplify the investigations of low-to-moderate risk incidents.

If you are in some other industry, TapRooT® will help you achieve great results investigating both minor incidents and major accidents with techniques that will help you no matter what level of complexity your investigation requires.

One more question that you might have for us ,,,

How does TapRooT® stay one (or more) steps ahead of the industry?

 That’s easy.

  • We work across almost every industry in every continent around the world. 
  • We spend time thinking about all the problems (opportunities for improvement) that we see. 
  • We work with some really smart TapRooT® Users around the world that are part of our TapRooT® Advisory Board. 
  • We organize and attend the annual Global TapRooT® Summit and collect best practices from around the world.

 We then put all this knowledge to work to find ways to keep TapRooT® and our clients at the leading edge of root cause analysis and performance improvement excellence. We work hard, think hard, and each year keep making the TapRooT® Root Cause Analysis System better and easier to use.

If you want to reduce the cumulative impact of your corrective action program, get the latest TapRooT® Book and attend our new 2-Day TapRooT® Root Cause Analysis Course. You will be glad to get great results while saving time and effort.




Medical Errors – 3rd Leading Cause of Death in the US

Posted: May 4th, 2016 in Accidents, Current Events, Medical/Healthcare

Medical Death Chart

Wow. Quite an eye-opening Washington Post article describing a report published in the BMJ. A comprehensive study by researchers at the John Hopkins University have found that medical mistakes are now responsible for more deaths in the US each year than Accidents, Respiratory Disease, and Strokes. They estimate over a quarter million people die each year in the US due to mistakes made during medical procedures. And this does NOT include other sentinel events that do not result in death.  Researchers include in this category “everything from bad doctors to more systemic issues such as communication breakdowns when patients are handed off from one department to another.”  Other tidbits from this study:

  • Over 700 deaths each day are due to medical errors
  • This is nearly 10% of all deaths in the US each year

What’s particularly alarming is that a study conducted in 1999 showed similar results.  That study called medical errors “an epidemic.”  And yet, very little has changed since that report was issued.  While a few categories have gotten better (hospital-acquired infections, for example), there has been almost no change in the overall numbers.

I’m sure there are many “causes” for these issues.  This report focused on the reporting systems in the US (and many other countries) that make it almost impossible to identify medical error cases.  And many other problems are endemic to the entire medical system:

  • Insurance liabilities
  • Inadequate reporting requirements
  • Poor training at many levels
  • Ineffective accountability systems
  • between patient care and running a business

However, individual health care facilities have the most control over their own outcomes.  They truly believe in providing the very best medical care to their patients.  They don’t necessarily need to wait for national regulations to force change.  They often just need a way to recognize the issues, minimize the local blame culture, identify problems, recognize systemic issues at their facilities, and apply effective corrective actions to those issues.

I have found that one of the major hurdles to correcting these issues is a lack of proper sentinel event analysis.  Hospitals are staffed with extremely smart people, but they just don’t have the training or expertise to perform comprehensive root cause analysis and incident investigation.  Many feel that, because they have smart people, they can perform these analyses without further training.  Unfortunately, incident investigation is a skill, just like other skills learned by doctors, nurses, and patient quality staff, and this skill requires specialized training and methodology.  When a facility is presented with this training (yes, I’m talking about TapRooT®!), I’ve found that they embrace the training and perform excellent investigations.  Hospital staff just need this bit of training to move to the next level of finding scientifically-derived root causes and applying effective corrective actions, all without playing the blame game.  It is gratifying to see doctors and nurses working together to correct these issues on their own, without needing some expensive guru to come in and do it for them.

Hospitals have the means to start fixing these issues.  I’m hoping the smart people at these facilities take this to heart and begin putting processes in place to make a positive difference in their patient outcomes.


Weekly Wisdom: Simple Things Can Lead to Progress.

Posted: May 3rd, 2016 in Wisdom Quote


“Teach thy tongue to say, “I do not know,” and thou shalt progress.” -Maimonides

Technically Speaking – Customer Satisfaction Survey Prize Winner

Posted: May 3rd, 2016 in Software, Technical Support, Technically Speaking

Here at System Improvements, customer satisfaction is very important to us. We strive to ensure our customers’ questions are treated in a timely and efficient manner.

This is so important to us that it’s actually part of our Technical Support Mission Statement:

To provide timely, courteous and effective technical support to System Improvements staff and all TapRooT® customers, achieving customer satisfaction and process efficiency.

In order to ensure we are providing great service, we have implemented a new customer satisfaction rating system, where our customers can rate their experience with our Support Team. The initial feedback has been extremely valuable to us.

As a thank you to all our customers who take the time to fill out a Survey, all respondents are entered into a monthly drawing to win a TapRooT® polo shirt.

Everyone, congratulate Rob Mendoza from Tidewater as the polo shirt winner for the month of April!

This just in!

Posted: May 2nd, 2016 in Summit

Summit newsflash!

We just got confirmation that two special guests will be at the 2016 Global TapRooT® Summit reception on August 3, 2016 at the Westin Riverwalk, San Antonio!


Grab your western wear and get ready for the best reception ever!!!

If you come cowboy’d (or girl’d) up, you may just win a prize!

We hope to see YOU at the 2016 Global TapRooT® Summit!

Special thanks to Nicki Burwinkle, Director of First Impressions, for artistic direction on this shoot, and Alison Diggs, Operations Manager, for helping John Wayne out with a “thumbs up”!

TapRooT® Public Courses in Canada

Posted: May 2nd, 2016 in Courses


Edmonton, Canada

Upcoming TapRooT® Public Courses

Niagara Falls | 5-Day | July 11, 2016 Edmonton | 2-Day | July 12, 2016

For more information regarding our public courses around the world, click here.

REGISTER FOR THE 2016 TapRooT® Summit NOW. 

Monday Accident & Lessons Learned: “We are going to find out who is to blame for this …”

Posted: May 2nd, 2016 in Accidents, Career Development Tips, Current Events, Investigations

“We are going to find out who is to blame because that is the frustrating part about health and safety accidents such as this. When we go back, when we read the report, we find out each and every time that it was preventable. That’s why we need to learn from this,” Kevin Flynn, Ontario’s labour minister, told reporters Tuesday afternoon. 

That’s a quote from CP 24, Toronto’s Breaking News. See the story and watch the video interview about the accident here:

Is there a lesson to be learned here?

Interestingly, the “contractor” performing the work in this accident was a branch of the Ontario government.

Answer Trivia and Enter to Win!

Posted: May 2nd, 2016 in Contest

Thanks for your entries to last month’s contest! We’ll announce the winner soon!

For this month’s contest, we thought we’d test your Summit knowledge! Answer the trivia question below, enter your contact information and we’ll randomly select a winner from those that answered correctly. Good luck!

Deadline to answer: May 31
The winner will receive the Grand Prize to thank you for joining TapRooT® in changing the way the world solves problems.

Create your own user feedback survey

Monday Motivation: How to get good advice.

Posted: May 2nd, 2016 in Career Development, Career Development Tips, Wisdom Quote

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Why are most of us willing to take advice from anyone? Friends, family and neighbors mean well (usually) but would you seek advice from a friend about money who doesn’t have money? Would you seek advice from a neighbor about health who is morbidly obese? Would you seek advice from a family member about a relationship who struggles with relationships?

Motivate yourself to seek out people who will give you the right advice. It takes extra effort because they may not be the people who surround you.  Two rules of thumb:

1. Carefully evaluate advice from someone who doesn’t have to live with the possible consequences.

2. Think seriously about the advice from someone who you wouldn’t trade places with on the matter.

Rail Accidents: It’s the Entire System that Matters

Posted: May 2nd, 2016 in Accidents, Equipment/Equifactor®, Investigations



On April 3rd, an Amtrak passenger train collided with a backhoe that was being used by railroad employees for maintenance.  Two maintenance workers were killed, and about 20 passengers on the train were injured.  For those that are not familiar with the railroad industry, I wanted to discuss a system that was in place that was designed to help prevent these types of incidents.

Many trains are being back-fitted with equipment and software that is collectively known as positive train control (PTC).  These systems include sensors, software, and procedures that are designed to help the engineer safely operate the train.  It is designed to allow for:

  • Train separation and collision avoidance
  • Speed enforcement
  • Rail worker safety

For example, as the train approaches a curve that has a lower speed limit, a train with PTC would first alert the engineer that he must reduce speed, and then, if this doesn’t happen, automatically reduce the speed or stop the train as necessary to prevent exceeding tolerance.  Another example is that, if maintenance is known to be occurring on a particular section of track, the train “knows” it is not allowed to be on that particular section, and will slow / stop to avoid entering the restricted area.  The system can be pretty sophisticated, but this is the general idea.

Notice that I described the system as a series of sensors, software, and procedures that make up PTC.  While we can put all kinds of sensors and software in place, there are still procedures that people must follow for the system to operate properly.  For example, in in order to know about worker safety restrictions on a particular piece of track, there are several things that must happen:

  • The workers must tell the dispatcher they are on a specific section of track (there are very detailed procedures that cover this).
  • The dispatcher must correctly tell the system that the workers are present.
  • The software must correctly identify the section of track.
  • The communications hardware must properly communicate with the train.
  • The train must know where it is and where it is going.
  • The workers must be on the correct section of track.
  • The workers must be doing the correct maintenance (for example, not also working on an additional siding).
  • If being used, local temporary warning systems being used by the workers must be operating properly.  For example, there are devices that can be worn on the workers’ bodies that signal the train, and that receive a signal from the train.
  • Proper maintenance must be performed on all of the PTC hardware and software.

As you can see, just putting a great PTC system in place involves more than just installing a bunch of equipment.  Workers must understand the equipment, its interrelation with the train and dispatcher, how the system is properly initialized and secured, the limitations of the PTC system, etc.  People are still involved.

For the Washington Amtrak crash, we know that there was a PTC system in place.  However, I don’t know how it was being employed, if it was working properly, were all the procedures being followed, etc.  I am definitely not trying to apportion any blame, since I’m not involved in the investigation.  However, I did want to point out that, while implementation of PTC systems is long overdue, it is important to realize that these systems have many weak points that must be recognized and understood in order to have them operating properly.

Humans will almost always end up being the weak link, and it is critical that the entire system, including the human interactions with the system, be fully accounted for when designing and operating the system.  Proper audits will often catch these weak barriers, and proper investigations can help identify the human performance issues that are almost certainly in play when an accident occurs.  By finding the human performance issues, we can target more effective corrective actions than just blaming the individual.  Our investigations and audits have to take the entire system into account when looking for improvements.

Understanding & Stopping Human Error – EXCLUSIVE 2-Day Course

Posted: April 29th, 2016 in Best Practice Presenters, Human Performance, Summit

LEARN MORE about this course.

This course is scheduled for August 1-2, 2016 in San Antonio, Texas just prior to the 2016 Global TapRooT® Summit.

Create a Customized Schedule for the 2016 Global TapRooT® Summit!

Posted: April 29th, 2016 in Summit, Summit Videos, Video Depot

Did you know that your Global TapRooT® Summit schedule is completely customizable? You can choose to add an exclusive 2-day Pre-Summit course or choose to switch sessions on your Summit track. Click the image below to go to the video and learn how.

Register now!

A Quote from Admiral Rickover…

Posted: April 28th, 2016 in Performance Improvement, Pictures


“Responsibility is a unique concept,
it can only reside and inhere in a single individual.
You may share it with others, but your portion is not diminished.
You may delegate it, but it is still with you.
You may disclaim it, but you cannot divest yourself of it.
Even if you do not recognize it or admit is presence, you cannot escape it.
If responsibility is rightfully yours, no evasion, or ignorance,
or passing the blame cna shift the burden to someone else.
Unless you can point your finger at the man who is responsible when something goes wrong,
then you never had anyone really responsible.” 

AFL-CIO releases “Death on the Job” Report

Posted: April 28th, 2016 in Accidents, Root Causes


For the 25th year, the AFL-CIO has produced a report about the the state of safety and health for American workers. The report states that in 2014, 4,821 workers were killed on the job in the U.S., and approximately 50,000 died from occupational diseases. This indicates a loss of 150 workers each day from hazardous conditions.

READ the full report.

Technically Speaking – Help Desk Humor

Posted: April 28th, 2016 in Software, Technical Support, Technically Speaking

HELP DESK. Two words that can instill fear in anyone. Take a look at the video below and see if you can relate.

What comes to mind after that video? Do you get a recollection of similar incidents with your own Help Desk? You would rather just sit at your desk and not work than have to call the help desk. Is this due to past negative experiences with the Help Desk or just a fear of being given a solution you could have figured out yourself? Regardless of the reason, calling the help desk is often a dreaded task. Let’s take a look at two ways your local IT department can help you feel more empowered when a call to the Help Desk is required:

1. Human Engineering – Do you find that you and your colleagues constantly hit the wrong button and cause unexpected behavior when using a particular application?  That sounds like a design flaw. Updating that software in a way that prevents those accidental clicks can greatly reduce the number of calls to the local IT department.

2. Improved Training Programs – Not all of us are computer experts. We struggle with the basics at times even when the computer works properly. However, one area that is often overlooked in training is what do to if something goes wrong. Often times more than a reboot of your computer is required to resolve an issue. An improved training program including resolutions for common issues can greatly empower the user and ensure that when they contact the Help Desk, it’s due to a less common or possibly more significant issue on the machine.

3. Improved Procedure Documentation – How many times have you tried to follow instructions for a software program only to come across a window or message not documented in the procedure? It can be very frustrating and often set the mood of a call to the Help Desk. What if procedures were properly documented to include all the steps and prompts the user will experience while completing the procedure? Or better yet, what if your IT department made a video of the procedure that you can watch and pause as your complete the same procedure yourself? Videos are great training tools and eliminate possible ambiguities in a written procedure.

These are only a couple ways to help take away some of the fears you may have when calling your Help Desk. I encourage you to share this article with your local Help Desk and let them know if you need assistance in training or documentation relation to your computer. Conversely, if you have an awesome Help Desk, let them know that you appreciate their assistance whenever you have a computer issue!

Technically Speaking is a weekly series that highlights various aspects of our Version 5 software, introduces you to the upcoming TapRooT® VI release and occasionally includes a little Help Desk humor.

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

TapRooT® Around the World: Las Vegas

Posted: April 27th, 2016 in Courses, Pictures, Training

Shout out to TapRooT® instructor, Heidi Reed, for sending in these great course photos from Las Vegas.

You have just one more chance to take TapRooT® training in Vegas in 2016 at that is December 5.  

I know it’s far out but time flies.  Mark your calendar and make plans to end the year on a high note!

Chemical Spray Final Exercise Rebar Collapse Final with John Rebar Collapse Final Exercise Course Photos Course Photos Chris Final Exercise Discussion

TapRooT® Around the World: Greece

Posted: April 27th, 2016 in Courses, Training

Special thanks to TapRooT® instructor, Derek Rutherford, who sent in these great pictures from a recent onsite TapRooT® course in Athens, Greece.

Want to find out how our training can be a perfect fit for your company’s needs? Contact us and request a quote or licensing information from our Implementation Specialists. We can come to your site and train.

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We started using TapRooT® in the mid 1990s after one of our supervisors wanted to instill a more formal process to our investigations…


Fortunately, I already had a plan. I had previously used TapRooT to improve investigations…

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