Root Cause Analysis Blog


Friday Joke: Why People Choose NOT To Use TapRooT®

Posted: July 31st, 2015 in Jokes

Here are the TOP TEN reasons why people DON’T use TapRooT® to find root causes:

10. They like the feeling of hopelessness when they can’t find a good answer.

9. They like wasting time implementing ineffective corrective actions.

8. They like visits from unhappy regulators after accidents.

7. They like doing things the hard way.

6. They always do the opposite things that the best-in-class companies are doing.

5. They like feeling unprepared when management reviews their incident investigation.

4. They like talking to unhappy clients about quality problems.

3. They like placing blame and don’t need to find root causes.

2. They like crisis management.

1. They like investigating incidents over and over again – it keeps them in practice!

Stop the Sacrifices

Posted: July 30th, 2015 in Accidents, Documents, Performance Improvement


Over a decade ago, I wrote this article to make a point about stopping construction fatalities. I’ve reposted it because it is missing from the archives. Does it still apply today? Perhaps it applies in many other industries as well. Let me know by leaving a comment.

StopSacrifices.pdf (click to open the pdf)

What does a bad day look like?

Posted: July 30th, 2015 in Pictures

Screen Shot 2014 11 07 at 10 29 32 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

TapRooT® Public Courses in Central & South America

Posted: July 30th, 2015 in Courses


Monterrey, Mexico

Upcoming TapRooT® Public Courses:

Central America: 

Monterrey, Mexico | 5-Day | August 24, 2015 (Language: Spanish)

South America: 

Sao Paulo, Brazil | 5-Day | August 17, 2015 (Language: Portuguese)

Bogota, Colombia | 2-Day | August 26, 2015 (Language: Spanish)

Bogota, Colombia | 3-Day | August 26, 2015 (Language: Spanish)

Sao Paulo, Brazil | 2-Day | September 17, 2015 (Language: Portuguese)

Bogota, Colombia | 2-Day | September 22, 2015 (Language: Spanish)

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

Public TapRooT® Course in Stavanger, Norway

Posted: July 30th, 2015 in Courses, Local Attractions



Who is joining us in beautiful Stavanger, Norway for the TapRooT® Public Course coming up September 9, 2015?  Stavanger is known for many things such as one of Europe’s energy capitals, host of the Offshore Northern Seas (ONS) energy conference and a capital of culture. A beneficial learning experience through a 2-Day TapRooT® Incident Investigation Course along with sightseeing and experiencing a new city, what more could you want?


NoodleNoodle: If you love asian style and flavored noodles, this is your place. The locals love it and the tourists rave about it.

Cardinal: You can’t go to a country in Europe without visiting a local, proper pub, right? Enjoy the best that Norway has to offer at Cardinal.

Dognvill Bar & Burger: Something a little familiar, something a little local. Try the Norwegian spin on the hamburger, you won’t be disappointed.


Flor og Fjaere: Norwegian botanical gardens. You don’t need to be a botanist to appreciate a paradise like this.

Museums: Stavanger has several museums that have been a crowd-favorite among tourists. Try one or all!

-Canning Museum

-Maritime Museum

-Petroleum Museum

Viking Stadium: Catch a game of football (American soccer) to experience the love that Norwegians have for this beloved sport.


Ready to Register? Click here.

Interested in other Public Courses we offer? Click here. 

Want to inquire about an Onsite Course? Click here.

When is a safety incident a crime? Would making it a corporate crime improve corporate and management behavior?

Posted: July 29th, 2015 in Accidents, Current Events, Human Performance


I think we all agree that a fatality is a very unfortunate event. But it may not be a criminal act.

When one asks after an accident if a crime has been committed, the answer depends on the country where the accident occurred. A crime in China may not be a crime in the UK. A crime in the UK may not be a crime in the USA. And a crime in the USA may not be a crime in China.

Even experts may disagree on what constitutes a crime. For example, University of Maryland Law Professor Rena Steinzor wrote an article on her blog titled: “Kill a Worker? You’re Not a Criminal. Steal a Worker’s Pay? You Are One.” that her belief is that Du Pont and Du Pont’s managers should have faced criminal prosecution after an accident at their LaPorte, Texas, facility. She cited behavior by Du Pont’s management as “extraordinarily reckless.”

OSHA Chief David Michaels disagrees with Professor Steinzor. He is quoted in a different article as saying during a press conference that Professor Steinzor’s conclusions and article are, “… simply wrong.”

The debate should raise a significant question: Is making an accident – especially a fatal accident – a corporate crime a good way to change corporate/management behavior and improve worker safety?

Having worked for Du Pont back in the late 1980’s, I know that management was very concerned about safety. They really took safety to heart. I don’t know if that attitude changed as Du Pont transformed itself to increase return on equity … Perhaps they lost their way. But would making poor management decisions a crime make Du Pont a safer place to work?

Making accidents a crime would definitely making performing an accident investigation more difficult. Would employees and managers cooperate with ANY investigation (internal, OSHA, or criminal) IF the outcome could be a jail sentence? I can picture every interviewee consulting with their attorney prior to answering an investigator’s question.

I believe the lack of cooperation would make finding and fixing root causes much more difficult. And finding and fixing the root causes of accidents is extremely important when trying to improve safety. Thus, I believe increased criminalization of accidents would actually work against improving safety.

I believe that Du Pont will take action to turn around safety performance after a series of serious and sometimes fatal accidents. I think they will do this out of concern for their employees. I don’t think the potential for managers going to jail would improve the odds that this improvement will occur.

What do you think? Do you agree or disagree. Or better yet, do you have evidence of criminal proceedings improving or hindering safety improvement?

Let me know by leaving a comment below.


TapRooT® Public Courses in Europe, Africa & Middle East

Posted: July 29th, 2015 in Courses


Aberdeen, Scotland

Upcoming TapRooT® Public Courses:


Stavanger, Norway | 2-Day | September 9, 2015

Stavanger, Norway | 3-Day | September 9, 2015

Hamburg, Germany | 2-Day | September 14, 2015

Aberdeen, Scotland | 5-Day | September 21, 2015


Johannesburg, South Africa | 5-Day | August 24, 2015

Middle East: 

There are no upcoming public courses scheduled for August and September in this region. Check back frequently for updates or inquire about an onsite course.


Job Openings for People with TapRooT® Root Cause Analysis Training

Posted: July 29th, 2015 in Job Postings

Have you learned to use the TapRooT® System to find and fix the root causes of problems? If so, here are some employers interested in your skills:

NABU Quality Manager – TESCO Corporation – Houston, TX, USA

Reliability EngineerD22 Jurong, Jurong Island, Tuas, Singapore

Safety Specialist – Danos – Louisiana, USA

What’s the most important information in a root cause analysis?

Posted: July 29th, 2015 in Root Cause Analysis Tips

Welcome to this week’s root cause tips column. So what is the most important information or criteria in a good root cause analysis? (By the way, this is a trick question)

I started a list:

• A timeline of what happened
• Complete evidence
• Identification of causal factors
• Safeguards analysis (what failed)
• Safeguards Analysis (what worked)
• Root Causes substantiated by evidence
• Generic (system) Causes identified
• Corrective Actions that eliminate the root causes
• Corrective Actions that are implemented
• Corrective Actions that have been verified effective

So what do you think? Have I missed anything? Please comment below if you have any other ideas.

And which are the most important?

Yes, it is a trick question. They are ALL important.

For example, what if you did a really good job of collecting evidence and got good root causes but wrote weak corrective actions? Have you ever seen training as a corrective action for root causes that had nothing to do with training? Of course you have, that’s my point.

TapRooT® is a systematic process, software, and training for finding the real root causes of problems.

TapRooT® is a systematic process, software, and training for finding the real root causes of problems.

What if you had great corrective actions but they were never implemented (or checked to see if they were effective)?

The fact of the matter is you have to have all these things for an effective investigation and root cause analysis. It is easy to miss things, we’re all human and we all have different experiences, knowledge, and biases. But the good news is that this is all built into how TapRooT® functions. Just follow the process and you will have a good root cause analysis.

You must know WHAT happened before you can determine why. This is why evidence collection is so important.

You must know WHY before you can write corrective actions. If you do not have good evidence you will miss causal factors and root causes. ALL root causes have to be substantiated with evidence.

You must FIX the root causes. Your corrective action has to specifically address the root causes, has to be implemented, and has to be verified.

Think of it as a chain link fence. If any part of the chain is broken, the fence is compromised, and in this case, so is your investigation.

If you are interested in learning the TapRooT® Root Cause Analysis, our 2-day course offers all the process essentials needed to conduct an investigation including:

  • SnapCharT® – a simple, visual technique for collecting and organizing information to understand what happened.
  • Root Cause Tree® – a systematic, repeatable way to find the root causes of human performance and equipment problems — the Root Cause Tree® helps investigators see beyond their current knowledge.
  • Corrective Action Helper® – help lead investigators “outside the box” to develop effective corrective actions.

Check out our schedule for a course near you:

I hope I’ve given you some food for thought. Thanks for visiting our blog and happy investigating.

3 Characteristics that Separate Leaders from Managers

Posted: July 29th, 2015 in Career Development, Career Development Tips



A manager and a leader have two very different yet critical roles for the success of every business. It is extremely rare to find an individual who can serve both roles.

It may seem intuitive to know which role you’re in, but sometimes a manager will find himself miserable in a position because he is a leader, and a leader doing a manager’s job is like trying to fit a round peg into a square hole.

Knowing whether you are a leader or a manager helps you fit into the organizational structure of your company, and benefits both you and the company.

Here are three primary differences between and manager and a leader:


Manager: You’ve been told you’re the “brains of the business.”

Leader: You’ve been told you “inspire action” with your ideas.

Manager: You set exciting goals, i.e., how many green widgets will be produced and sold this week.

Leader: You respectfully question exciting goals, i.e., is the sale of green widgets in line with our company’s core values?

Manager: You major in the “how” and “when,” establishing systems, operating procedures and incentive programs.

Leader: You major in the “what” and “why,” establishing the mission statement, long-term vision, and the direction of the company.

People ask the difference between a leader and a boss. The leader leads and the boss drives. ~ Theodore Roosevelt

While it’s true that some managers inspire and some leaders can create great systems, these are not their primary strengths.

Have you ever left a position because you were managing instead of leading, or vice versa?

Do you consider yourself an investigative team leader? We’d love to see you in our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training!  Check out our Global Schedule for a course near you!

Simple Corporate Turnaround – Go from a money losing operation to a money making good example.

Posted: July 28th, 2015 in Performance Improvement, Pictures

How do you go from being a money losing operation to a money making good example?

Here’s a quick answer:

1. Send at team to TapRooT® Root Cause Analysis Training.

2. When they get back to work, put them to work solving your most expensive problems.

Don’t think this will work? Then see this success story…

Want more proof? See the rest of the success stories at:

If you need to improve your sites profitability, learn to use TapRooT® Root Cause Analysis to solve operational and maintenance problems. See our public course schedule for courses being held around the world at:


Weekly Wisdom: Stay focused on what’s important

Posted: July 28th, 2015 in Wisdom Quote


“We become what we think about.” -Earl Nightingale

How far away is death?

Posted: July 28th, 2015 in Video

From last year …

TapRooT® Public Courses in Canada

Posted: July 27th, 2015 in Courses


Calgary, Canada

Upcoming TapRooT® Public Courses:

Calgary | 2-Day | August 18, 2015

St. John’s | 2-Day | August 25, 2015

Edmonton | 2-Day | September 21, 2015

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

Final presentations at the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course

Posted: July 24th, 2015 in Courses, Pictures, TapRooT

Great work by all participants! Here’s one of the presentations and the audience …

IMG 5511

IMG 5507


Friday Joke: Enforcement NI

Posted: July 24th, 2015 in Jokes, Video

Need to improve your enforcement? Try Terry Tate!

Public TapRooT® Course in Monterrey, Mexico

Posted: July 23rd, 2015 in Courses, Local Attractions


Are you planning to join TapRooT® in Monterrey, Mexico for a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training (Spanish) on August 24, 2015?

Monterrey is one of the largest cities in Mexico, and is home to many important industries and businesses such as CEMEX and Mercedez-Benz Mexico. Not only is it an industrial hub, it’s filled with culture and beauty, as well. This city is surrounded by the Sierra Madre Oriental mountains which have public trails and canyons for anyone to admire the natural beauty that Monterrey has to offer. We still have a few spots left, you won’t want to miss this opportunity to travel and gain knowledge to benefit your company.


El Gaucho: This warm, friendly restaurant offers classic Mexican cuisine that can cater to all pallets.

Sante Fe: In the mood for a little fine dining? Sante Fe offers all the best gourmet dishes, wines and desserts.

Bread Panaderos: Everyone loves a fresh bread bakery that also serves freshly ground coffee. Order a snack or a whole loaf to take home with you.


Horno 3: A museum of technological history, innovations and interactive exhibits must be interesting. Check out this museo del acero to find out for yourself.

Parque Fundidora: This large municipal park is always hosting activities for all ages and is a great place for site seeing the beautiful city.

Planetario Alfa: Museums and an IMAX Theater all in one. Take a tour through Mexican history or watch the latest educational movie in the state of the art IMAX Theater.

REGISTRATION, click here.

For more information regarding our other Public Courses, click here.

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