Root Cause Analysis Blog


TapRooT® Course in Aberdeen

Posted: December 1st, 2015 in Courses, Pictures

Recent 5-Day TapRooT® Course in Aberdeen, Scotland. Students learning the Advanced Root Cause Analysis and Team Leader Training.

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For more information on TapRooT® courses, click here.

Caption Contest Winner!

Posted: December 1st, 2015 in Contest, Pictures

After 45 entries to our November Caption Contest, the results are in! Yesterday, 18 TapRooT® employees voted on their top two favorite entries, and although all of them made us laugh, only two could win.

The Grand Prize Winner of the miniature, antique globe is…*drum roll*… Kreg Worrest!

Kreg’s caption: “Use your head – drive safely.”

The Runner Up and the winner of bragging rights is…*drum roll*…Fred M!

Fred’s caption: “Duck, WHAT DUCK?”


Congratulations Kreg and Fred! 

Here is the image they captioned:



We will be launching a new contest for December soon. Check our blog or the e-newsletter next week and enter. You could be our next winner!

TapRooT® User Best Practice Tip

Posted: December 1st, 2015 in RCA Tip Videos, Summit Videos, Video Depot

Here is a root cause tip from one of our users, Sam Dillow, that can be used across industries. TapRooT® users share best practices at the Summit, and it is one of many highlights of our conference.

Thanks for the tip, Sam!

(CLICK HERE if the video is not displaying.)

Weekly Wisdom: Have You Found Out Why?

Posted: December 1st, 2015 in Wisdom Quote

WW born

“The two most important days in your life are the day you are born and the day you find out why.” -Mark Twain

Career Development: Don’t Be a Quitter!

Posted: November 30th, 2015 in Career Development, Career Development Tips


Being successful means learning how to finish well … no matter what!

Ever notice how the beginning of anything new is full of excitement and enthusiasm, but it’s hard to keep excitement and enthusiasm going? Being successful means learning how to finish well … no matter what! It’s part strategy and part willpower. There are always a few obstacles to endure and overcome. Life can’t be all fun and games.

But don’t be a quitter! Here are 8 steps to being an achiever!

  1. Evaluate times that you quit in the past. When are you most likely to give up? What were your reasons for quitting in the past? Can you think of a strategy for getting through those times? Is there a way to avoid them altogether?
  2. Invest your time wisely. Getting caught up in too many meaningless projects won’t improve your ability to finish things. When possible, limit yourself to those things that really interest you. Life is too short for hobbies that make you want to shrug. If you’re passionate about something, you’re much more likely to get it done.
  3. Chart your progress. When you can visually see how much progress you’ve made, you’ll feel more motivated to continue. Make a chart, graph, or other visual representation of the work you’ve completed.
  4. Visualize the expected result. Constantly remind yourself how great you’ll feel when you’re done. Make note of all the benefits you’re receive.
  5. Be realistic. If you haven’t logged several thousand hours of piano practice before your 30th birthday, it’s unlikely you’ll ever reach the level of a world-class pianist. This is especially true if you’re 58 years old, have a family, and only have 30 minutes a day to practice.  However, you can still play! You can still become a better pianist!
  6. Give yourself a reasonable amount of time. You might be making good progress, but if you believed that you should’ve mastered the Russian language by now, you’ll become discouraged. It’s not easy to estimate the amount of time it will take to complete something. Do you have a history of thinking that things will take less time than they actually do? Build a fudge-factor into your estimates. After you’ve make a little progress, revisit your expectations and adjust them accordingly. If you’re enjoying yourself, who cares how long it takes? Once you’re done, the fun is over!
  7. Get better at the small things first. If you’re washing the dishes, avoid leaving that greasy, disgusting pan until morning. Fold all the clothes rather than leaving some of them for later. Clean the entire room. Pay all of the bills. Run the full 3 miles you planned to run.  Get in the habit of finishing all of the tasks in your life.
  8. Be immune to criticism. One of the reasons we stop before completing a project is to avoid criticism. Once it’s done and available for the world to judge, we can get apprehensive. Then we rationalize reasons not to complete it. The people that matter won’t be unkind. The unkind people don’t matter. There’s no way to stop the criticism, but you don’t have to allow it to bother you.

These small tips can be a great help in finishing future projects. If there’s one trait you’ll find in high-achievers, it’s the ability to get things done. Learn how to finish and change your life!

Monday Accident & Lessons Learned: Is Training the Right Corrective Action for this Fatal Accident?

Posted: November 30th, 2015 in Accidents, Current Events, Investigations, Pictures, Root Causes

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Here is a link to the significant incident report:

It seems from the report that the appropriate seat belt was present. Therefore the only applicable action in the “Action required” section is:

Workers should be instructed, through training and inductions, regarding the importance of using the seatbelts provided in vehicles to reduce the impact of potential collisions.” 

In my instant root cause analysis using the Root Cause Tree®, I wonder why there wasn’t a Standards, Policies, and Administrative Controls Not Used Near Root Cause. That would get me to dig more deeply into the Enforcement NI root cause. 

What do you think? Was this a training root cause that needs a training corrective action?

Leave your comments below…

TapRooT® Public Courses in Canada

Posted: November 30th, 2015 in Courses

CalgaryIslandCalgary, Canada

Upcoming TapRooT® Public Courses:

Calgary | 5-Day | January 25, 2016

Edmonton | 2-Day | February 18, 2016

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

Friday Joke: Not Encouraging

Posted: November 27th, 2015 in Jokes, Medical/Healthcare

A man was seen fleeing down the hall of the hospital just before his operation.

What’s the matter?” he was asked.

He said, “I heard the nurse say, ‘It’s a very simple operation, don’t worry, I’m sure it will be all right.

She was just trying to comfort you, what’s so frightening about that?

She wasn’t talking to me. She was talking to the doctor.

What does a bad day look like?

Posted: November 26th, 2015 in Pictures

Screen Shot 2014 11 07 at 10 27 14 PM

Want to see more of these? “What Does a Bad Day Look Like” is a column in our weekly eNewsletter (distributed every Tuesday) that often makes our subscribers feel they are having a pretty good day!  If you’d like to subscribe, contact Barb at

Public TapRooT® Course in Aberdeen, Scotland

Posted: November 25th, 2015 in Courses

Course photos from a Public TapRooT® Course in Aberdeen this past week.







For more information on our Public Courses, click here.

To inquire about an Onsite Course, click here.

Safeguard Analysis for Finding Causal Factors

Posted: November 25th, 2015 in Investigations, Root Cause Analysis Tips, Root Causes

A Causal Factor is nothing more than a mistake or an equipment failure that, if corrected, could have prevented the incident from happening.

Once you’ve gathered all the information you need for a TapRooT® investigation, you’re ready to start with the actual root cause analysis. However, it would be cumbersome to analyze the whole incident at once (like most systems expect you to do). Therefore, we break our investigation information into logical groups of information, called Causal Factor groups. So the first step here is to find Causal Factors.

Remember, a Causal Factor is nothing more than a mistake or an equipment failure that, if corrected, could have prevented the incident from happening (or at least made it less severe).  So we’re looking for these mistakes or failures on our SnapCharT®.  They often pop right off the page at you, but sometimes you need to look a little harder.  One way to make Causal Factor identification easier is to think of these mistakes as failed or inappropriately applied Safeguards.  Therefore, we can use a Safeguard Analysis to identify our Causal Factors.

There are just a few steps required to do this:

First, identify your Hazards, your Targets, and any Safeguards that were there, or should have been there.

Now, look for:

- an error that allowed a Hazard that shouldn’t have been there, or was larger than it should have been;

- an error that allowed a Safeguard to be missing;

- an error that allowed a Safeguard to fail;

- an error that allowed the Target to get too close to a Hazard; or

- an error that allowed the Incident to become worse after it occurred.

These errors are most likely your Causal Factors.

Let’s look at an example.  It’s actually not a full Incident, but a VERY near miss.  This video is a little scary!


Let’s say we’ve collected all of our evidence, and the following SnapCharT is what we’ve found.  NOTE:  THIS IS NOT A REAL INVESTIGATION!  I’m sure there is a LOT more info that I would normally gather, but let’s use this as an example on how to find Causal Factors.  We’ll assume this is all the information we need here.

Picture1 Picture2

Now, we can identify the Hazards, Targets, and Safeguards:

Hazard Safeguard Target
Moving Train Fence Pedestrians
Pedestrians (they could have stayed off the tracks)

Using the error questions above, we can see that:

- An error allowed the Hazard to be too large (the train was speeding)

- An error allowed the Targets to get too close to the Hazard (the Pedestrians decided to go through the fence, putting them almost in contact with the Hazard)

These 2 errors are our Causal Factors, and would be identified like this:

Picture3 Picture4

We can now move on to our root cause analysis to understand the human performance factors that lead to this nearly tragic Incident.

Causal Factors are an important tool that allow TapRooT® to quickly and accurately identify root causes to Incidents.  Using Safeguard Analysis can make finding Causal Factors much simpler.

Sign up to receive tips like these in your inbox every Tuesday. Email Barb at and ask her to subscribe you to the TapRooT® Friends & Experts eNewsletter – a great resource for refreshing your TapRooT® skills and career development.

Best Wishes to Harry Thorburn

Posted: November 24th, 2015 in Pictures, TapRooT® Instructor

Today, Instructor Harry Thorburn delivered his final TapRooT® course. Harry has been an instructor with Matrix Risk Control and System Improvements for the past 5 years. We hate to see him go, but we wish him the best of luck and a happy retirement.


Harry with his final TapRooT® students.


Matrix Director, Mhorvan Sherret, giving Harry a token of appreciation.

Weekly Wisdom: Run Your Day.

Posted: November 24th, 2015 in Wisdom Quote

WW run the day

“Either you run the day, or the day runs you.” -Jim Rohn

Monday Accident & Lessons Learned: What do you think of this Root Cause Analysis…

Posted: November 23rd, 2015 in Accidents, Investigations, Performance Improvement

On November 6, I wrote about a “Safety Pause” at Savannah River Nuclear Solutions.

The last paragraph of the article was:

Let’s hope that the root cause analysis of the incident will explore the management system related failures that led to the reasons for the degraded emphasis on nuclear safety and security that caused the ‘Pause’ to be needed and not be an example of the blame game that points the finger at workers and low level supervisors and their actions.

So here is what the Aiken Standard wrote about the SRNS root cause analysis:

Following a root cause analysis of the incident, Spears said the incident was a result of the work team’s willful procedure violation and its unwillingness to call a time out. As a result, the contractor addressed the job performance of individuals using the SRNS Constructive Discipline Program and took appropriate disciplinary actions, according to SRNS.”

What do you think? Did they look into Management System causes?

If they don’t find and fix the Management System causes … how will they prevent a future repeat of this incident? 

In my experience, very seldom is someone a “bad person” that needs to be corrected using a discipline system. Usually, when someone breaks the rules, it is because a culture of rule breaking (or expediency) has taken hold in order to deal with unrealistic goals or unworkable procedures. 

I don’t think I have ever seen a team of bad people. If a “team” has gone bad (especially if a supervisor is involved), I would bet that the culture of expediency has been promoted. This bunch was just unfortunate enough to get caught in a serious incident and were handy to blame. No reason to look for any Management System causes. 

This is how a culture of expediency exists alongside a culture of blame. 

What can you learn from this incident?

One reason you use the TapRooT® System for root cause analysis is to find Management System root causes and fix them so that your management and employees don’t slip into a culture of expediency and blame. 

Are you doing “spare time” root cause analysis?

Posted: November 19th, 2015 in Root Cause Analysis Tips


Don’t get caught in these scenarios – make root cause analysis an integral part of your improvement program.

 Do these scenarios look familiar to you?

Here’s scenario #1:

An incident occurs.

The supervisor performs a 5-Whys analysis, or maybe just does a few interviews with a few employees out on the plant floor. The supervisor collects just enough information to fill out the company report, or to satisfy his manager because this is a task done in his spare time. Once someone or something is found to pin the cause on, the supervisor thinks of a solution, (typically an employee gets disciplined or a piece of equipment gets fixed), and the root cause analysis is complete.

The downside to doing root cause analysis in your spare time like this is you’ll probably see repeat incidents. You’ll miss root causes or not get to the root. So, instead of saving time doing the investigation in your spare time, you have created more work.  Plus, you are working within your own knowledge.  You may be very experienced, but a bias (and we all have them) can cause you to overlook important information.  Also, morale will be affected because employees do not want to live under the fear of punishment if they make a mistake. And let’s not forget when near misses and small problems aren’t solved, chances are a major incident is building on the horizon.  Don’t let your facility be the next headline!

Here’s scenario #2:

An incident occurs.

The supervisor performs a TapRooT® investigation in his or her spare time. Her company does not have a blame culture– hooray! She only had time to attend one day of a 2-day TapRooT® course, but the former supervisor showed her the basics. The supervisor uses the Root Cause Tree® as a “pick list,” (without using a Root Cause Tree® Dictionary to dig deeper – she is not even aware there is a dictionary), until one root cause and a couple of causal factors are found.  Sigh of relief. Corrective actions to the root cause are implemented.  Check! This root cause analysis is complete!

The downside to this TapRooT® “spare time” root cause analysis is similar to scenario #1 in that you will probably experience repeat incidents because you’ll miss root causes that won’t be fixed, and there was not sufficient training on the TapRooT® tools.  You may progress beyond your own knowledge in identifying root causes using the Root Cause Tree® and that’s a plus, but you may not be casting a wide enough net by using all of the tools in the TapRooT® system.  Take shortcuts and don’t use all the tools available to you, and you will lose the power of TapRooT® to effectively guide you in your root cause analysis to find and fix incidents.

Don’t be that supervisor!

To get the full benefit of TapRooT®, join us at a course to receive all of these tools and understand how to use them:

SnapChart® – a visual technique for collecting and organizing information to understand what happened.
Root Cause Tree® – a way to see beyond your current knowledge (with additional help from the Root Cause Tree® Dictionary)
Corrective Action Helper® – a tool to help you think “outside the box” to develop effective corrective actions.
Safeguard Analysis – identify and confirm causal factors

This is how you find all the root causes and fix them once and for all.  Smaller problems are also found before they turn into major disasters.  It’s a win for everyone!

Are you doing spare time root cause analysis?  There is still time to join us for a course in 2015 and make 2016 a different story.

Learn more here:
2-Day TapRooT® Incident Investigation and Root Cause Analysis Course
5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Cross Industry/Cross Discipline Benchmarking for Performance Improvement

Posted: November 19th, 2015 in Performance Improvement, Summit

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Had an interesting discussion today about cross industry / cross discipline performance improvement benchmarking.

It seems that many people benchmark inside their industry. Oil industry people benchmark with oil industry people. Heathcare with Healthcare. Nuclear with Nuclear. The list goes on and on.

Also, safety people go to safety conferences. Quality people go to quality conferences. Maintenance and reliability people go to maintenance and reliability conference.

So, I had someone ask me where they could do cross industry/cross discipline benchmarking. Nuclear safety people with Pharmaceutical Quality folks. Aviation safety folks with healthcare quality people. Refining process safety folks with Aviation safety people.

The answer? Plan on attending the 2016 Global TapRooT® Summit on August 1-5 in San Antonio.

We don’t have the final schedule out yet but it will be out soon. But I can guarantee that there will be sessions from all sorts of experts and people attending from all sorts of industries and disciplines. That’s what is so special about the TapRooT® Summit. We make a special effort to get people from different industries and different disciplines together to meet, make friends, and benchmark their improvement initiatives.

So start planning to attend.

There will be people there from all over the world.

And consider bringing a team from your company that includes people from safety, process safety, quality, operations, and maintenance. Contact us by clicking HERE for information about group discounts.

Hope to see someone from every TapRooT® User company (and some folks who are only thinking about using TapRooT®) there!

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