Root Cause Analysis Blog


Users Share Best Practices: Running a Four Day Course

Posted: October 20th, 2016 in Root Cause Analysis Tips, Summit, Summit Videos, Video Depot

Our 2016 Global TapRooT® Summit was a great success this year! Our attendees helped one another by sharing some of their best practices. Larry Perkinson shares how his company teaches a four day TapRooT® course that includes a day dedicated to exams. What a great idea!

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Who far away is death?

Posted: October 20th, 2016 in Accidents, Video

Enhance Your Equifactor® Skills in Houston

Posted: October 20th, 2016 in Equipment/Equifactor®, Local Attractions

Equipment problems can be difficult, but fixing them is vital for safety in the workplace and efficiency in production. Where do you start? Find the root cause of the failure. But how? Come to a TapRooT® Equifactor® public course to learn how to find that root cause, develop effective solutions and implement them successfully. Our systematic process is reliable, and your equipment should be, too.

Well, good news! TapRooT® is offering this course in Houston on November 3. You can learn how to optimize your equipment and enjoy a city with a big personality. Houston lives up to the western character that many assume they’ll find, but that’s not all it is. You’ll find cuisine of all kinds, sophisticated downtown shops and industrial powerhouses of all kinds. Visit and see for yourself!

Join TapRooT® in Houston for this local public course.

Inquire about an Equifactor® onsite course for your company.

Technically Speaking – Helpdesk Humor

Posted: October 20th, 2016 in Uncategorized


Check out this great article for more details about “What’s Wrong With Cause-and-Effect, 5-Why’s, & Fault Trees”

Technically Speaking is a weekly series that highlights various aspects of the TapRooT® VI software and occasionally includes a little Help Desk humor.

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

What does a bad day look like?

Posted: October 18th, 2016 in Video

Users Share Best Practices: Defining Your Focus

Posted: October 18th, 2016 in Root Cause Analysis Tips, Summit, Summit Videos, Video Depot

Our 2016 Global TapRooT® Summit was a great success this year! Our attendees helped one another by sharing some of their best practices. Here Steven Sandlin discusses his best practice of defining the focus. What is the minimum threshold that drives an investigation?

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Monday Accident & Lessons Learned: Aviation Safety Reporting System CALLBACK Notice About Ramp Safety

Posted: October 17th, 2016 in Accidents, Current Events, Investigations

CALLBACK Report Ramp Safety

Here’s the start of the report …

This month CALLBACK features reports taken from a crosssection of ramp experiences. These excerpts illustrate avariety of ramp hazards that can be present. They describethe incidents that resulted and applaud the “saves” made bythe Flight Crews and Ground Personnel involved.

For the complete report, see:

You Can, You Should & If You’re Brave, You Will

Posted: October 17th, 2016 in Career Development, Career Development Tips

Recently hiked to the top of House Mountain in Corryton, Tennessee. The climb can be rough in spots, but worth the view. Isn’t it always?

Ahhhhh the bucket list! I’ve been thinking about mine again lately. The 2007 movie inspired many of us with adventurous spirits to do more. So grateful to be living my bucket list adventure today!  Sometimes the best thing you can do for your career development is to do something different.

You can, you should, and if you’re brave enough to start, you will. – Stephen King

If you haven’t made a bucket list, you’re missing an easy opportunity to live a more fulfilled life. A bucket list defines where you want to spend your resources before other non-essential things swallow them up. We all have a limited number of resources (and an expiration date), but few of us live like we do.


How to Create a Bucket List


  1. Choose different types of activities that enhance your primary areas of life. For optimal life balance, we all have six primary areas to attend to: physical wellness, emotional wellness, spirituality, relationships, finances and careers. You might include a few physical challenges, like hiking a mountain trail. Or plan a few adventures with your family or friends, like indoor skydiving (did that, highly recommend!). It might be fun to include a few intellectual and travel items that will enhance your career development. Maybe you’ve even thought about earning extra money by turning a hobby into a business.
  2. Don’t overwhelm yourself with too many items to check off. Your list is not set in stone, it can change over time, but always prioritize your list. Start with a “top 10” list. The top items on your list will be more meaningful to you than all of the rest of the list combined. Assuming it will take years to check off all the items, your list will change. You’re changing, so it’s only reasonable to expect your list to change too.
  3. Pick one thing that you can do this weekend. It might be buying tickets to see your favorite musician in concert or signing up for guitar lessons. Give yourself a feeling of accomplishment right off the bat. Some of the best things can be simple and easy. For example, traveling by car for a day trip adventure is easier than traveling to another country. Have bucket list items that range in difficulty from simple to difficult.
  4. Set goals that support items that will be challenging to achieve on your bucket list. If you want to live in Sonoma, California when you retire, you might set some financial goals and sign up for a wine tasting class. An easy first step is just buying a calendar with photos of Sonoma and hanging it by your desk so you can see it every day and keep the dream alive. Remember to review your goals regularly and remind yourself why you’re pursuing them.

Every day you’re writing a page of the story of your life, make it a good one!

Do you have a bucket list? Inspire others by sharing what you’ve checked off!

Root Cause Analysis Training in Denver!

Posted: October 13th, 2016 in Courses, Local Attractions


Denver is a city of change and forward-thinking growth. Through the years, it has managed to keep it’s iconic midwestern, adventurous feel, while also adding a whole slew of new characteristics. This city is vibrant and well-rounded, you won’t be disappointed! Come check it out with TapRooT® November 3-4 for a 2-Day Incident Investigation public course to get the essential root cause analysis training you need to improve performance.

Things to do and eat:

Root Down: This “field to farm” unique Denver restaurant is a crowd favorite.

Sweet Action Ice Cream: Everyone loves classic chocolate & vanilla, but this local parlor creates flavors all its own.

Denver Art Museum: What better way to learn about Colorado’s Native American history and culture?

Confluence Park: A beautiful park to see the nature-side of Denver through trails, kayaking or tubing.



Find another public course near you

Inquire about an onsite course for your company

Technically Speaking – Dashboard Widgets

Posted: October 13th, 2016 in Software, Technical Support, Technically Speaking, Uncategorized

What’s a widget you ask?? If you would have asked me this question when I was a child, I would have told you that Widget was the name of my family pet cat. But today, the term widget means something else to me in regards to software. A widget is a small application within a webpage that provides useful information. You may be familiar with widgets that you use on your iPhone or Smartphone.

Well in TapRooT® VI, widgets exist to provide valuable trending data on your incidents, investigations, audits, root causes and corrective actions. Currently, if you were to visit the DASHBOARD menu, you would find just 4 basic widgets. But I am excited to announce that in our near future release we have COMPLETELY enhanced this dashboard with a variety of widgets and custom options to help meaningfully display your data.

Want to know which Basic Cause Categories, Near Root Causes or Root Causes are your biggest offenders? Want to know which locations or classifications have the most issues? Want to know how many complete, incomplete or past due Corrective Action tasks you have? These dashboard widgets will let you know. There are almost 25 widgets that can be viewed in over 70 combination display types to help you focus on exactly what sort of information you want to see. Take a look.

dashboard widgets


You can choose from a variety of display chart types including Table Chart, Pie Chart, Horizontal or Vertical Bar Charts, Line Charts AND Pareto Charts.

You can filter by date range, location and classification to really drill down to that level of detail that you may want to understand.

dashboard filter

Want to print a copy of your charts? You can export them to PDF and save or print to share with others.

Customize your dashboard to display your most frequently displayed widgets every time you visit the dashboard.

Slice it, dice it, anyway you want to see it. These little widgets pack a lot of big power and information. You can look forward to seeing these new features VERY soon!


Technically Speaking is a weekly series that highlights our TapRooT® VI software and occasionally includes a little Help Desk humor.

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

Root Cause Tips – Defense in Depth (layers of protection)

Posted: October 12th, 2016 in Root Cause Analysis Tips

Happy Wednesday and welcome to this week’s Root Cause Analysis Tip.

The topic this week is the concept of “Defense in Depth.” You may have also heard terms such as Barrier Analysis or LOPA (layer of protection analysis). In TapRooT®, we use the term Safeguards.

Take a look at this diagram (courtesy of Mark Paradies, the creator of TapRooT®):

Screen Shot 2016-10-07 at 10.43.31 AM

What the diagram depicts is an incident where several layers of protection have been breached. You may have also heard of Reason’s “Swiss Cheese Model.” In these models we can see that we only have incidents when all layers are breached. So the amount of layers and strength of those layers determine if (and how often) we have incidents. It is also why sometimes things go wrong but we do not have an incident; because one or more layers worked.

So our goal in developing processes is to make sure we have enough layers and that the layers are functioning the way we want. Remember that every Safeguard has a hole in it, it is not infallible. So we want to make the holes as small as possible.

The same applies to corrective actions. Do we need new layers? How can we strengthen existing layers?

The concept is easy. What is difficult is determining just how much is enough.

Risk really is the main driver of that in my view, but business realities come into play as well. The easy ones are the ones on either side of the spectrum. For example, something is fairly difficult but low risk – probably all you need is a procedure and some training (we refer to these as Quasi-Safeguards).

If something is difficult AND high risk, we need a lot of layers, and hopefully many of them are engineering controls.

The hard ones are the ones in the middle; a process is very easy and there is very little chance of a problem… BUT, the risk is very high – in this case determining what you need can be very difficult.

In my November column, I will talk about the strength of Safeguards.

In closing, I urge you to think about Defense in Depth when developing processes. Audit them to make sure the layers are functioning. And if you do have an incident think about Safeguards and Defense in Depth when developing your corrective actions.

Have you been to our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training?  Learn more about advanced techniques like Safeguards Analysis, Change Analysis, Critical Human Action Profile (CHAP) and Cognitive Interviewing.

Thanks for visiting the blog, and enjoy your week.

Equipment Reliability: What Happens as Pumps Wear Out?

Posted: October 11th, 2016 in Equipment/Equifactor®

Equipment reliability - Pump wear

When we are faced with the prospect of installing a new pump, we have to take a look at several factors to decide what the best course of action will be. For example, we have to look at:
– Fit for purpose
– Initial cost
– Life-cycle maintenance costs
– Electrical efficiency
– Ease of maintenance
– etc.

An additional consideration is how the characteristics of the pump vary over time.  It is fairly straight forward to calculate flow rates and pressures using the specs of a new pump.  However, how do these specs vary over time?  As the pump wears, how will the characteristics of the pump change, and how will this affect the overall fitness of the pump for the service environment?

Here is a nice article that describes how pump nameplate characteristics will change as the pump wears, and what to expect as the components wear.

Weekly Wisdom: Reflect.

Posted: October 11th, 2016 in Wisdom Quote

Screen Shot 2016-10-05 at 3.19.23 PM

Users Share Best Practices: Including Positives in Your Report

Posted: October 10th, 2016 in Root Cause Analysis Tips, Summit, Summit Videos, Video Depot

Our 2016 Global TapRooT® Summit was a great success this year! Our attendees helped one another by sharing some of their best practices. Watch Matt Deluhery discuss his best practice of including positives found during an investigation. These include noting safeguards that worked as well as individuals that stepped up during the recovery process.

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Monday Accident & Lessons Learned: UK RAIB Report on Derailment at Paddington Station in London

Posted: October 10th, 2016 in Accidents, Current Events, Investigations, Pictures


Summary from the UK Rail Accident Investigation Branch …

At 18:12 hrs on Thursday 16 June 2016, a two-car diesel multiple unit train, operated by Great Western Railway (GWR), was driven through open trap points immediately outside Paddington station and derailed. It struck an overhead line equipment (OLE) mast, damaging it severely and causing part of the structure supported by the mast to drop to a position where it was blocking the lines. There were no passengers on the train, and the driver was unhurt. All the the lines at Paddington were closed for the rest of that evening, with some services affected until Sunday 19 June.

For causes and lessons learned, see:

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