Root Cause Analysis Blog


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

IMG 2125

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!

Upcoming Public TapRooT® Course in Lake Charles, LA

Posted: November 19th, 2015 in Courses, Local Attractions


Join TapRooT® in Lake Charles on December 15 for a 2-Day Incident Investigation and Root Cause Analysis Public Course. 

Acadania, the official title for the French Louisiana region. This area is a major cultural and educational center in the Southwest United States. Lake Charles is a diverse area containing a major petrochemical refining center, gaming center, home to McNeese State University, and the Festival Capital of Louisiana, with over 75 festivals held annually. Especially in December, Lake Charles is a great vacation spot with its tropical climate and Southern hospitality.


Tony’s Pizza: A popular Lake Charles pizza place with the areas best salads, pastas, pizzas, Po Boys and more.

Pujo Street Café: Classic Louisiana cuisine as well as a wide selection of burgers and sandwiches. The Shrimp Bisque is a crowd favorite and a Pujo Street Café tradition.

Pats of Henderson: Authentic Cajun kitchen serving Lake Charles for more than 50 years. Gumbos, crawfish, frog legs, and alligator, it doesn’t get more Cajun than that.


Creole Nature Trail: One of the first National Scenic Byways and considered one of America’s “Last Great Wildernesses”. Enjoy this more than 180-mile stretch through Louisiana’s Outback.

Graywood Championship Golf Course: . Named one of Golf Digest’s top 100 public courses in the country, and ESPN ranked it as “extraordinary” in its review of the country’s top golf clubs. It’s a must for all players.

The Mardi Gras Museum of Imperial Calcasieu: This museum features the largest collection of Mardi Gras Costumes on the Gulf Coast. Take in the heart behind Louisiana’s culture.

Want to register? Click here.

Inquire about an Onsite Course here.

What does a bad day looks like?

Posted: November 19th, 2015 in Pictures

Like this for a sports writer … Howard will never live this one down …

Screen Shot 2015 06 09 at 4 31 02 PM

TapRooT® Public Courses in Oceania & Asia

Posted: November 19th, 2015 in Courses


Adelaide, Australia

Upcoming TapRooT® Public Courses:

Queensland Australia: 

Brisbane | 2-Day | December 10, 2015

Brisbane | 2-Day | January 12, 2016

Western Australia:

Perth | 2-Day | December 7, 2015

Perth | 2-Day | January 11, 2016

 Victoria Australia:

Melbourne | 2-Day | January 19, 2016

South Australia:

Adelaide | 2-Day | January 27, 2016


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

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

TapRooT® Public Courses in Central & South America

Posted: November 19th, 2015 in Courses


Monterrey, Mexico

Upcoming TapRooT® Public Courses:

Central /South America: 

Monterrey, Mexico | 2-Day | February 17, 2016

Monterrey, Mexico | 3-Day | February 17, 2016


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

One step closer to fusion power.

Posted: November 18th, 2015 in Video

With an MS in Nuclear Engineering, I couldn’t help but post this video…

Think they will need root cause analysis?

New Chemical Process Safety Video from CCPS

Posted: November 18th, 2015 in Video

System Improvements is a member company of CCPS.

Find and Fix the Root Causes of Equipment Related Failures

Posted: November 18th, 2015 in Courses, Equipment/Equifactor®

Don’t end up “fixing” the same equipment problems over and over again. Don’t let equipment issues cause quality, operations, and safety issues. Find the real root causes of your equipment reliability issues and develop effective fixes that will keep them from happening again by using this systematic process.

Did you know that we have 3-day and 1-day courses? What’s the difference? 3-Day Courses include the 1-Day Equifactor® Course along with the 2-Day Incident Investigation and Root Cause Analysis Course so you have it all in one. The 1-Day courses are just the separate Equifactor® course that requires a previously taken 2-Day course along with it, not necessarily all in one trip.

Why take an Equifactor® course? You will not only receive invaluable knowledge for your business, but also a Free single-user copy of TapRooT® Software. (A $2890 Value!) You can’t get a better deal than that.

Still deciding? Watch the video below to hear our Equifactor® instructor, Ken Reed, talk about why this course is right for you.


Steps to register for the course and Free Software.


2) Select a 1-Day Equifactor® Course of your choice (Having already taken a 2-Day course or accompanying it with a 2-Day course)

3) Register for the course and add it to your cart

4) Done!


Upcoming Equifactor® Public Courses:

Las Vegas, NV | December 4, 2015

Adelaide, Australia | January 29, 2016

Monterrey, Mexico | February 17, 2016

What is Strategy?

Posted: November 18th, 2015 in Career Development, Career Development Tips

Time and resources are limited, and lack of strategy is a good way to run out of both before you reach a goal. In this Slideshare, Mark Sniukas defines strategy and walks us through it.

TapRooT® Course in Kazakhstan

Posted: November 17th, 2015 in Courses, Pictures


Pictures of a great TapRooT® course taught Kazakhstan recently.






For more information on our Public Courses, click here.

For more information on our Onsite Courses, click here.

How Far Away is Death?

Posted: November 17th, 2015 in How Far Away Is Death?, Pictures

What could happen when this lets go?

IMG 2221

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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…


Many of us investigate accidents that the cause seems intuitively obvious: the person involved…

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