Root Cause Analysis Blog


What is the Root Cause of Happiness?

Posted: November 21st, 2014 in Career Development, Career Development Tips

What do you think is the root cause of happiness?



Good looks?



happyWell, many people think that any or all of the above are root causes of happiness, but research has indicated that those things really don’t provide a long-lasting feeling of contentment. In fact, one of the most important things you can possess to ensure a lifetime of happiness is a character trait that anyone can develop: gratefulness.

Since Thanksgiving is just around the corner, it’s a good time to think about what we are thankful for and enjoy the bonus of feeling happier.

What, exactly, does an attitude of gratitude do for our well-being that contributes to life-long happiness? So much!

Here are some of the benefits of practicing gratefulness:

  • reduced risk of heart disease and cancer;
  • a stronger immune system;
  • increased productivity;
  • improved decision making;
  • increased achievements;
  • better interpersonal relationships;
  • a better self-image;
  • more respect from others;
  • less stress;
  • reduced feelings of jealousy;
  • happier memories (research has indicated gratefulness helps us remember the good stuff in life and minimize the negative);
  • a feeling of well-being;
  • stronger resilience;
  • more energy;
  • better sleep; and
  • a longer life.

Want some ideas on how to cultivate an attitude of gratefulness? The University of California, Berkeley published 10 great tips by Robert Emmons including using visual reminders; watching your language; and thinking outside the box by seeking new things to be grateful for.

Here’s another tip: grateful people mindfully use social media in a positive way. So post an inspirational quote or this article on your social media, and you will not only grow in your practice of gratefulness but encourage others to take this meaningful path as well.

TapRooT® Summit Attendees Share Favorite Aspects of the Summit

Posted: November 21st, 2014 in Uncategorized

Tune in to this week’s Global TapRooT® Summit’s testimonial. Listen to how attendee, Mujeeb Rahman, plans to use the knowledge he took away from the Summit back at his workplace.

Don’t have time to watch the video? Read the dialogue below.

Mujeeb, what do you like about our Summit this year?

“It was wonderful. Just to experience different individuals, the sharing of new techniques, it was really helpful. I, myself, attended the Pre Summit breakout course and it was really really helpful. Especially some of the techniques that I wish I had before. Had I known about it, I could have saved so much time, costs, on time delivery that I can use, actually, in the quality of the supply chain side would bring a lot of benefit to my company.”

Great, well we’re so glad you came this year and we look forward to seeing you next year.

Want more information regarding the 2015 TapRooT® Summit? Click Here

Ready to register for the 2015 TapRooT® Summit? Registration opens December 1, 2014!

What does a bad day look like?

Posted: November 20th, 2014 in Pictures

See, your day isn’t so bad…

Screen Shot 2014 09 04 at 12 24 59 PM

Root Cause Analysis Video Tip: TapRooT® Resources That Will Help You Be Proactive.

Posted: November 19th, 2014 in Performance Improvement, Root Cause Analysis Tips, TapRooT® Instructor, Video

Dave Janney, Senior Associate and instructor for TapRooT®, shares with us today the many TapRooT® resources that will help you be proactive in your company’s investigations. Dave also discusses the importance of being proactive; you might think that your company doesn’t have the resources (time, money, etc.) to spend to be proactive but it will cost you even more resources to let the incidents build up. Prevent them from happening using TapRooT® proactive resources such as the Root Cause Tree®, SnapCharT and Root Cause Tree Dictionary.

For more information regarding our Public and Onsite TapRooT® Courses, click here.

Want to join us at the Global TapRooT® Summit? Click here for more information and registration.


Was this tip helpful? Check out more short videos in our series:

Conduct Real-Time Peer Reviews with Mark Paradies (Click here to view tip.)

What Makes a World-Class Root Cause Analysis System with Ken Reed (Click here to view tip.)

TapRooT® & Healthcare: Getting the Most from Your Sentinel Event Investigation with Ed Skompski (Click here to view tip.)


TapRooT® Around the World: Europe, Africa and the Middle East

Posted: November 19th, 2014 in Courses


Aberdeen, Scotland

Upcoming TapRooT® Public Courses:

Dubai, UAE 5-Day December 7, 2014

London, England 5- Day December 8, 2014

Aberdeen, Scotland 5-Day January 26, 2015

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

Find and Fix the Root Causes of Equipment Related Failures

Posted: November 19th, 2014 in Uncategorized

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.


Watch this video for more information regarding Equifactor® course.


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:

Bogota, Colombia | December 3, 2014

Edmonton, Alberta | December 4, 2014

Las Vegas, Nevada | December 10. 2014

Calgary, Alberta | January 16, 2015

Remembering An Accident: San Juanico Disaster

Posted: November 19th, 2014 in Accidents

On November 19, 1984, a series of explosions caused one of the deadliest industrial accidents in the history of the world.  The explosions occurred at a storage and distribution facility for liquified petroleum gas belonging to Petroleos Mexicanos. It is believed that the explosion started with a gas leak which caused a plume that grew large enough to be transported by the wind and reach a flare pit where it ignited.

The explosions and fires demolished most of the town of San Juan Ixhuatepec, and it is estimated that up to 600 people died and 5,000 – 7,000 people suffered severe injuries. The fire created such an inferno that most corpses were reduced to ashes, making it hard to determine who perished.


Learn more about the disaster.

When something catastrophic happens, companies often discover a series of errors and process flaws that were present all along. Advanced root cause analysis skills can help you uncover these error and flaws.  Visit our training page to find a course near you:



TapRooT® Around the World: Course Photos from Birmingham, England

Posted: November 19th, 2014 in Courses, Pictures

Thanks to Harry Thorburn for these pictures of such a great course in Birmingham, England.




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

How Far Away is Death?

Posted: November 18th, 2014 in Video

Watch the sailor almost become toast…

TapRooT® Around the World: U.S.A.

Posted: November 18th, 2014 in Courses


Houston, Texas

Upcoming TapRooT® Public Courses:

Houston, TX 2-Day January 22, 2015

New Orleans, LA 5-Day January 26, 2015

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

Weekly Wisdom for Quality & Root Cause Analysis

Posted: November 18th, 2014 in Wisdom Quote



“Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction, and skillful execution; it represents the wise choice of many alternatives.”

- William A. Foster

TapRooT® Around the World: Canada

Posted: November 17th, 2014 in Courses, Pictures


St. John’s, Newfoundland

Upcoming TapRooT® Public Courses:

Calgary 2-Day January 14, 2015

Calgary 3-Day January 14, 2015

St. John’s 2-Day January 19, 2015

Edmonton 5-Day January 19, 2015

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


Posted: November 17th, 2014 in Current Events, Investigations, Pictures


This incident occurred whilst drilling the first well following new rig commissioning and start-up. While drilling into suspected sand, the rig experienced a kick. The well was shut in with 180 psi Shut In Drill Pipe Pressure SIDPP), 14 BBLS gained, 270 psi Shut In Casing Pressure (SICP), 12.3 PPG MW (surface) in the hole. Several attempts were made to circulate; pipe was stuck and packed off. A riser mud cap of 13.4 PPG was installed and the well monitored through the choke line (static). The well was opened and monitored to be static. The stuck pipe was freed, circulation re-established and the well was again shut it. The Driller’s Method was then used to displace the influx from the well.

During the first circulation, a high gas alarm, from the shaker exhaust sensor, initiated a rig muster. The well was shut in and monitored. The shaker gas detectors and ventilation were checked and found operable. As the well kill was re-started, mud vented from the Mud Gas Separator (MGS) siphon breaker line, and all the shaker gas sensors alarmed. The rig was called to muster a second time. The well was shut in (indications were that gas had blown through the degasser liquid seal) and monitored. The liquid seal was lost and the well was immediately shut in. The liquid seal was flushed again and well kill started up but again lost the liquid seal and the well was shut in. Further investigation of the MGS identified a blind skillet plate in the spool piece between the MGS and main gas vent line which blocked the normal path for gas flow and misdirected the gas to the shaker room. The skillet plate had been installed during construction to prevent rainwater from entering the MGS.

The blind skillet plate was removed and the well kill re-started without further incident. No injuries were reported.

NewImageFigure 1: Blind flange located on top of vessel near deck ceiling. Not easily detected.


Figure 2Removed blind flange from the 12” vent line of the mud gas separator.

What Went Wrong?

  1. Uncertainty about the pore pressure below base of salt resulted in the mud weight being too low to prevent an influx.
  2. Malfunction of the mudlogger gas sampling system during drilling operations led to unrepresentative gas unit data.
  3. A 12-in blind skillet plate installed in the MGS main gas vent line during rig construction was not removed before operations began.
  4. Personnel on the rig did not fully understand the operation of the MGS to prevent subsequent gas releases in the shaker room.

Corrective Actions and Recommendations

  1. Include in rig contractors’ procedures for rig acceptance, flange management procedures to ensure that temporary blanking flanges or skillets, installed during construction or commissioning, are removed prior to hand-over to operations. Verification of rig contractor’s procedures to be in operator’s practices.
  2. Develop detailed instructions and procedures for preventative maintenance and calibration of the surface mud logging gas detection equipment that includes daily visual inspection of the gas trap impeller. Documentation for inspection and maintenance is to be maintained on the rig.
  3. Include critical items provided by Third Parties in the Safety Critical Equipment list and its associated controls.
  4. Implement awareness training for rig crews on the MGS Operating Procedure, LEL readings, mudlog gas detection, and significance and consequence of gas releases.

Source Contact

Safety alert number: 261 OGP
Safety Alerts


Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the OGP nor any of its members past present or future warrants its accuracy or will, regardless of its or their negligence, assume liability for any foreseeable or unforeseeable use made thereof, which liability is hereby excluded. Consequently, such use is at the recipient’s own risk on the basis that any use by the recipient constitutes agreement to the terms of this disclaimer. The recipient is obliged to inform any subsequent recipient of such terms.

This document may provide guidance supplemental to the requirements of local legislation. Nothing herein, however, is intended to replace, amend, supersede or otherwise depart from such requirements. In the event of any conflict or contradiction between the provisions of this document and local legislation, applicable laws shall prevail.


2014 Global TapRooT® Summit Attendees Share Favorite Aspects from the Summit

Posted: November 14th, 2014 in Summit, Testimonials, Video

Steve Lerner shares what he will be taking back to his workplace to improve his organization after attending his very first TapRooT® Summit. Check it out:

Don’t have time to watch the video? Read the dialogue below.

What do you think about the Summit?

“I think the Summit is absolutely awesome. I had a great time. Learned quite a bit of stuff. Networking with hundreds of different people with what they do and what works for them and what’s not working for them and finding out that our problems are not just our problems. Most everybody is going through some of the same things.”

So, what would you say to your co-workers about the Summit?

“Yes, we need to come to the Summit more often since this is my first one.”

Have you learned any best practices that you’ll be taking back? 

“Yes, we had a couple of really good ideas, actually. The best practices that we created over the last couple of months, we are going to add going into corrective actions and digging deeper into tracking corrective actions. Not just talking about TapRooT® itself, but how effective are our corrective actions that we’re coming up with?”

Well, we’re glad that you came and got to see how great our Summit is and we hope that you will be back next year.


For more information regarding the upcoming Global TapRooT® Summit in June, 2015, click here. 

What does a bad day look like?

Posted: November 13th, 2014 in Pictures

Is your day really that bad?

Screen Shot 2014 09 04 at 12 22 35 PM

TapRooT® Around the World: London, England

Posted: November 13th, 2014 in Uncategorized


Join the TapRooT® team on December 8, 2014 for a 5-Day Advance Root Cause Analysis Team Leader Training public course in London, England!

London has grown to the top of the list in leading global cities with strengths in education, entertainment, finance, healthcare, professional services, research and development, and, of course, tourism. After reviewing their international arrivals last year, London is also the world’s most visited city. There is no doubt that their historical heritage is what so many tourists long to see and experience.


The Five Fields: Interested in trying new fresh gourmet flavors? The Five Fields has a multitude of options.

The Andover Arms: A local pub with a fun atmosphere and delicious London favorites.

The Art of Pizza:  If you love pizza, this is a must try! The Art of Pizza home-makes all dough and sauce to create the best pizza around.


Houses of Parliament Tour:  Visit, in person, the UK Parliament buildings you’ve only seen in movies and textbooks.

The National Gallery:  Appreciate the Arts with exhibits containing pieces by Rembrandt and Monet.

Hippodrome Casino: Enjoy a night out on the town at London’s Casino of the year.


To register: click here

For more information regarding our many international public courses: click here.

For information regarding our upcoming Global TapRooT® Summit: click here.


Root Cause Analysis Tip: Top 10 Investigation Mistakes (in 1994)

Posted: November 12th, 2014 in Investigations, Performance Improvement, Pictures, Root Cause Analysis Tips

Gatlinburg Sunrise 1

At the first TapRooT® Summit in Gatlinburg, Tennessee, in 1994, attendees voted on the top investigation mistakes that they had observed. The list was published in the August 1994 Root Cause Network™ newsletter (© 1994). Here’s the top 10:

  1. Management revises the facts. (Or management says “You can’t say that.”)
  2. Assumptions become facts.
  3. Untrained team of investigators. (We assign good people/engineers to find causes.)
  4. Started investigation too late.
  5. Stopped investigation too soon.
  6. No systematic investigation process.
  7. Management can’t be the root cause.
  8. Supervisor performs investigation in their spare time.
  9. Fit the facts to the scenario. (Management tells the investigation team what to find.)
  10. Hidden agendas.

What do you think? Have things change much since 1994? If your management supports using TapRooT®, you should have eliminated these top 10 investigation mistakes.

What do you think is the biggest investigation mistake being made today? Is it on the list above? Leave your ideas as a comment.

TapRooT® Around the World: Course Photos from Copenhagen, Denmark

Posted: November 12th, 2014 in Courses, Pictures

Thanks to one of our Instructors, Ken Reed, for providing these great pictures. Always hard at work at TapRooT® courses.






Want more information regarding TapRooT® Public Courses around the world? Click here.

How Far Away is Death?

Posted: November 11th, 2014 in Pictures

Sent to me by a TapRooT® User…

It all took about 2 minutes. This is a case of 1 photographer photographing a 2nd photographer. The following photos were taken by Hans van de Vorst from the Netherlands at the Grand Canyon, Arizona. The descriptions are his own. The identity of the photographer in the photos is unknown.


I was simply stunned seeing this guy standing on this solitary rock at The Grand Canyon. The canyon’s depth is 900 meters (3000ft) here. The rock on the right is next to the canyon and is safe. Watching this guy wearing flip-flop sandals, with camera and tripod.

I asked myself 3 questions:

  1. How did he get onto that rock?
  2. Why not take that sunset picture from the rock to the right, – which is perfectly safe?
  3. How will he get back?

After the sun set behind the canyon’s horizon, he packed his things (having only one free hand) and prepared himself for the jump. This all took about 2 minutes.

At that point he had the full attention of the crowd of tourists.


He’s now at the point of no return. He jumped in his flip-flops.


Now you can see that the safe rock is higher so he had to land lower, which was quite steep, and tried to use his one free hand to grab the rock.


Look carefully at the photographer. He has a camera, a tripod and also a plastic bag, all on his shoulderbor in his left hand. Only his right hand is available to grab the rock. And the weight of his stuff is a problem. He lands low. Both his right hand and right foot are slipping.

At that very moment, I take this shot. He then pushes his body against the rock, waits for a few seconds,

Throws his stuff up on the flat rock, climbs up and walks away.

Presumably to a bathroom to change his shorts.

I know I had to change mine and I was just watching!

Hans van de Vorst

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