Root Cause Analysis Blog


A Quote from Admiral Rickover…

Posted: April 28th, 2016 in Performance Improvement, Pictures


“Responsibility is a unique concept,
it can only reside and inhere in a single individual.
You may share it with others, but your portion is not diminished.
You may delegate it, but it is still with you.
You may disclaim it, but you cannot divest yourself of it.
Even if you do not recognize it or admit is presence, you cannot escape it.
If responsibility is rightfully yours, no evasion, or ignorance,
or passing the blame cna shift the burden to someone else.
Unless you can point your finger at the man who is responsible when something goes wrong,
then you never had anyone really responsible.” 

AFL-CIO releases “Death on the Job” Report

Posted: April 28th, 2016 in Accidents, Root Causes


For the 25th year, the AFL-CIO has produced a report about the the state of safety and health for American workers. The report states that in 2014, 4,821 workers were killed on the job in the U.S., and approximately 50,000 died from occupational diseases. This indicates a loss of 150 workers each day from hazardous conditions.

READ the full report.

Technically Speaking – Help Desk Humor

Posted: April 28th, 2016 in Software, Technical Support, Technically Speaking

HELP DESK. Two words that can instill fear in anyone. Take a look at the video below and see if you can relate.

What comes to mind after that video? Do you get a recollection of similar incidents with your own Help Desk? You would rather just sit at your desk and not work than have to call the help desk. Is this due to past negative experiences with the Help Desk or just a fear of being given a solution you could have figured out yourself? Regardless of the reason, calling the help desk is often a dreaded task. Let’s take a look at two ways your local IT department can help you feel more empowered when a call to the Help Desk is required:

1. Human Engineering – Do you find that you and your colleagues constantly hit the wrong button and cause unexpected behavior when using a particular application?  That sounds like a design flaw. Updating that software in a way that prevents those accidental clicks can greatly reduce the number of calls to the local IT department.

2. Improved Training Programs – Not all of us are computer experts. We struggle with the basics at times even when the computer works properly. However, one area that is often overlooked in training is what do to if something goes wrong. Often times more than a reboot of your computer is required to resolve an issue. An improved training program including resolutions for common issues can greatly empower the user and ensure that when they contact the Help Desk, it’s due to a less common or possibly more significant issue on the machine.

3. Improved Procedure Documentation – How many times have you tried to follow instructions for a software program only to come across a window or message not documented in the procedure? It can be very frustrating and often set the mood of a call to the Help Desk. What if procedures were properly documented to include all the steps and prompts the user will experience while completing the procedure? Or better yet, what if your IT department made a video of the procedure that you can watch and pause as your complete the same procedure yourself? Videos are great training tools and eliminate possible ambiguities in a written procedure.

These are only a couple ways to help take away some of the fears you may have when calling your Help Desk. I encourage you to share this article with your local Help Desk and let them know if you need assistance in training or documentation relation to your computer. Conversely, if you have an awesome Help Desk, let them know that you appreciate their assistance whenever you have a computer issue!

Technically Speaking is a weekly series that highlights various aspects of our Version 5 software, introduces you to the upcoming TapRooT® VI release and occasionally includes a little Help Desk humor.

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

TapRooT® Around the World: Las Vegas

Posted: April 27th, 2016 in Courses, Pictures, Training

Shout out to TapRooT® instructor, Heidi Reed, for sending in these great course photos from Las Vegas.

You have just one more chance to take TapRooT® training in Vegas in 2016 at that is December 5.  

I know it’s far out but time flies.  Mark your calendar and make plans to end the year on a high note!

Chemical Spray Final Exercise Rebar Collapse Final with John Rebar Collapse Final Exercise Course Photos Course Photos Chris Final Exercise Discussion

TapRooT® Around the World: Greece

Posted: April 27th, 2016 in Courses, Training

Special thanks to TapRooT® instructor, Derek Rutherford, who sent in these great pictures from a recent onsite TapRooT® course in Athens, Greece.

Want to find out how our training can be a perfect fit for your company’s needs? Contact us and request a quote or licensing information from our Implementation Specialists. We can come to your site and train.

athens.4 athens.3 athens.2 Athens.1

Confidential Medical Records Leak Sinks $4.6 Million Company

Posted: April 27th, 2016 in Current Events, Medical/Healthcare, Summit


What are the lessons learned from this incident?

Everything was going great for Michael Daughtery, owner of LabMD, a company that tested blood, urine, and tissue samples for urologists. He was living the dream. That is, until one of his managers who had been using LimeWire file-sharing to download music inadvertently shared patient medical records with it. It was a violation of company policy to have it on her computer.

The story goes from bad to worse. Read “A leak wonded this company. Fighting the Feds finished it off” on Bloomberg.

In one day, your whole life could change.  Wouldn’t it be great if you never got that phone call that disaster has struck your company?

We have several exclusive Pre-Summit Courses coming up in August that can help you keep your company from facing a crisis such as this.  TapRooT® for Audits, Understanding and Stopping Human Error, Risk Assessment & Management and more.

View them here.

We also offer a Medical track immediately following the special 2-day courses at the 3-day Global TapRooT® Summit.  Learn more here.

We hope to meet you in San Antonio, Texas during Global TapRooT® Summit week to help you solve your more business-critical issues.

TapRooT®: Committed to your Career Development!

Posted: April 27th, 2016 in Career Development, Career Development Tips


TapRooT® offers so much for your career development!  From training to root cause tips to motivational articles … we are committed to bringing value to your work week.

If you are not already a subscriber, subscribe to our Tuesday eNewsletter and don’t miss a thing!

Contact Barb at to subscribe today to get each week’s news delivered in one convenient eNewsletter.

Weekly Wisdom: Look Past the Fear.

Posted: April 26th, 2016 in Wisdom Quote

other side of fear

“Everything you’ve ever wanted is on the other side of fear.” George Adair

What Does a Bad Day Look Like?

Posted: April 26th, 2016 in Video

Certainly was an impressive way to arrive for the prom. But a bad day for the pilot!

Monday Motivation: Strong to the finish!

Posted: April 25th, 2016 in Career Development, Career Development Tips, Wisdom Quote

pablo (11)

Do you have a habit of committing to things, but not finishing them? While getting started is the first step to something great, many of us get stuck on the second step … thinking but not doing. Seldom do we consider the challenges that were not visible when we first started toward a goal.  However, a goal without commitment will never be reached unless you take action to overcome those challenges.

Where have you dropped your commitment?  What one action can you take today to pick it up?

Monday Accident & Lessons Learned: Human Error + Equipment Failure = 911 System Outage

Posted: April 25th, 2016 in Accidents, Current Events


The following sequence is from the Clarence Bee

First, an air conditioning unit for a power supply room failed.

No big deal … There’s an automatic backup and a system to notify the engineer.

Oops … It failed too.

Well, at least there is a local temperature alarm. The local maintenance guy will do the right thing … Right?

Sorry. In the “heat” of the moment, he pushed the “kill” button.

Unfortunately, this was for fire emergencies and it cut off all the power to the 911 system. And nobody knew how to reset it. 

Finally, the tech rep from Reliance Electric arrived and the system was restored – 3.5 hours after the kill switch was pushed.

What can you learn from this incident?

  • Do your people know what to do when things go wrong? 
  • Do you do drills? 
  • Are things clearly labeled? 
  • Are there response procedures? 
  • How long has it been since people were trained?

Conveyor Belt Maintenance Tips

Posted: April 25th, 2016 in Uncategorized

belt fire

We sometimes take conveyor belts for granted. “Just a motor, some rollers, and a big flexible belt.” But for those of us that use conveyor belts as a critical part of our business, we know how impactful a belt system failure can be.  Additionally, a failure can cause more than just an inconvenience; failures in your belt system can lead to overheating and serious fires.
Here are some good ideas to help keep your conveyor belts running smoothly and safely.

Ken Reed Invites You to The Asset Optimization Track at the 2016 Global TapRooT® Summit

Posted: April 22nd, 2016 in Best Practice Presentations, Equipment/Equifactor®, Summit, Summit Videos, Video, Video Depot

The Global TapRooT® Summit offers multiple focused learning tracks for performance improvement. This video introduces the Asset Optimization Track. Come to the Summit and maximize improvement at your company!

Starring Ken Reed. Produced by Benna Dortch.

Learn more about the Summit!

Interested in the Safety Track?  Learn about it here!

TapRooT® Public Courses in Oceania & Asia

Posted: April 21st, 2016 in Courses


Adelaide, Australia

Upcoming TapRooT® Public Courses:

Queensland Australia: Brisbane, 2-Day, May 17 | Gladstone, 2-Day, May 23 North Australia: Darwin, 2-Day, June 27 West Australia: Perth, 2-Day, May 12 | Perth, 2-Day, June 23 South Australia: Adelaide, 5-Day, May 2| Leeton, 5-Day, May 9 | Newcastle, 5-Day, May 9 | Sydney, 2-Day, June 20Victoria Australia:  Melbourne, 5-Day, June 6 New Zealand: New Plymouth, 5-Day, June 13

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

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

REGISTER FOR THE 2016 TapRooT® Summit NOW.

TapRooT® Public Courses in Central & South America

Posted: April 21st, 2016 in Courses


Sao Paulo, Brazil

Upcoming TapRooT® Public Courses:

Central America: 

There are currently no courses scheduled in this region. Schedule and Onsite Course today.

South America:

Sao Paulo, Brazil | 2-Day | June 13

Want a course in your region? Schedule and Onsite Course.

Heavy Equipment Maintenance Tips

Posted: April 21st, 2016 in Equipment/Equifactor®


I ran across these tips for keeping your heavy equipment operating at peak performance. Some may seem obvious, but it is amazing how many times I’ve seen these simple maintenance actions ignored, especially at smaller companies. Larger companies often have staff dedicated to their maintenance programs, but smaller companies sometimes just don’t feel they have the resources.  I was working with a company just recently who had had a near miss due to a missing equipment guard.  As we dug a little deeper, we realized that there was no formalized maintenance system in place for there basic equipment.  They expected the operators to notice, report, and oftentimes actually fix any issues with their equipment on their own.  That was the extent of the maintenance program!

Please take a look at your equipment maintenance programs.  If you have planned maintenance in place for most of your equipment, take a hard look at your other, ancillary equipment.  You may find the big stuff has a good program, but the smaller (yet still critical) equipment is missing required maintenance and inspections.

Technically Speaking – When is the PEN mightier than the KEYBOARD?

Posted: April 21st, 2016 in Software Updates, Technical Support, Technically Speaking

When System Improvements lets me out of my cage (the cage where all the code-monkeys bang on typewriters until the latest release of the TapRooT® Software is complete), I often find myself in a TapRooT® course. Next week, for example, I will be teaching the TapRooT® 2 Day Course in Portland, Oregon using the  TapRooT® VI software!

When mingling with the users of the TapRooT® Software at a course, I often get asked the question, “When should you use the software during your investigation and when should you perform the process without the software?”

I think people typically expect me to say, “ALWAYS use the Software!”, because, well, I’m fond of job security.  

But in reality, I believe The TapRooT® Software is a valuable tool in performing an investigation, but like any other tool, you should only use it to accomplish the appropriate task. Sometimes the PEN is mightier than the keyboard.


You would not use a chainsaw to unclog your toilet, would you?
If you answered, “No of course not!”, then keep reading.
If you answered, “Yes”, then maybe you should stop reading and go call a plumber.

So “When”, you ask, “do you use the software and when do you not?”
My answer, “Stop interrupting, I was just about to tell you!”

When you have a report of an incident and are just getting started, this is a great time to use the software. It is pretty simple to do:

• Enter 5 pieces of required information (Title, Description, Location, Classification, Date)

Pretty simple right?  Now you are in business, because the 7 Steps (or 5 Phases in Version VI) are going to guide you through the rest of the process.

The first step in that process is to create a new Spring SnapCharT® and add a few simple things to get your investigation started:

• Define your Incident (Circle Shape)
• Add the Events you know occurred (Rectangle Shape)
• Add QUESTIONS you want to ask when gathering evidence (Oval Shape)

After you do this, you are ready to go interview and gather evidence to answer those questions.

Can you type with the quickness of a stenographer, while making eye contact with who you are talking to and, oh yeah, remember to LISTEN?

Then hey, bring along the laptop, because you are a superhero (The Magnificent Multi-Tasker?).

If not, maybe a simple notepad (or tablet) and a print-out of your Planning SnapCharT® will be sufficient.   Although, TapRooT® VI DOES work on a tablet if you are feeling adventurous and mobile.

Once you have all your interviews done and your evidence collected, it is time to map out your sequence of events and build your SnapCharT®.

I actually recommend 2 different approaches at this stage. If you are doing an investigation by yourself, then by all means open up the software.

However, if you are part of an investigation TEAM, then you need to turn off that computer and projector.  You simply do not want an investigation team staring at a projector screen (or worse, a small laptop screen) as you assemble a SnapCharT® in the software.

Janet from EH&S will inevitably fall asleep and drool all over the conference table, Bobby from manufacturing is going to keep asking, “What does that button do?”, and Rick (who is supposed to be YOUR ASSISTANT) is going to keep pointing out your grammatical errors.  What is THERE, errr…. THEIR, problem?

So, bust out the sticky notes or a dry erase board and work it through as a team, ON YOUR FEET. You’ll be surprised at how engaging it can be. You can always take a picture of the results and easily assemble the SnapCharT® in the software later.

After you have a clear understanding of the sequence of events, and have added all the detail your conference room wallpaper can support in sticky notes, it is time for you to make like Han and go Solo.

Tell your team you will schedule another meeting to discuss Root Causes and Corrective Actions at a later date, after you have had some time to work through the findings.

Explain to them it is not them, it’s you. You just need some alone time to analyze the incident (and your feelings).

Are they gone? Okay, now it is time to fire up the software and:
• Recreate your SnapCharT® (while getting a soothing massage)
• Isolate your causal factors on your  SnapCharT® (during an avocado facial scrub)
• Run each causal factor through the Root Cause Tree® (while listening to Enya near a fountain)

Did you get to the Root Causes (and figure out why you lash out sometimes)? Well then…

Call up Janet, Bobby and Rick because it is time to reunite (it will feel so good)!

Review the Root Causes you found during your hiatus, but do not dare open up those Root Cause Trees® in the software! You are not here to revisit the past. You are here to move forward and make new catchy Corrective Actions that your audience (Management) is going to love to hear.

Feel free to use the software to consult the Corrective Action Helper® often. Work on that setlist until you have it perfected because the big show is coming up…

As you walk into the conference room, Janet, Bobby and Rick behind you, you know you have brought the goods to wow your audience (Management).

But what didn’t you bring? Your Root Cause Trees® or your FULL SnapCharT®s.

All you need to pull off the big show is your Presentation SnapCharT® (which you have pruned in the software to show only the information relevant to presentation), your Root Causes, and your Corrective Actions.

The lights dim, you take the stage…

Dan Verlinde is the Director of Information Technology and Software Development at System Improvements, Inc. When he and the code-monkeys are not making TapRooT® Software, he enjoys spa treatments, rock concerts, and poorly constructed analogies.

Technically Speaking is a weekly series that highlights various aspects of our Version 5 software, introduces you to the upcoming TapRooT® VI release and occasionally includes a little Help Desk humor.

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

Connect with Us

Filter News

Search News


Barb PhillipsBarb Phillips

Editorial Director

Chris ValleeChris Vallee

Six Sigma

Dan VerlindeDan Verlinde

Software Development

Dave JanneyDave Janney

Safety & Quality

Ed SkompskiEd Skompski


Gabby MillerGabby Miller

Communications Specialist

Ken ReedKen Reed


Linda UngerLinda Unger

Vice President

Mark ParadiesMark Paradies

Creator of TapRooT®

Steve RaycraftSteve Raycraft

Technical Support

Success Stories

Four years ago I was an incident investigator, an incident reviewer, and an investigation techniques…

Hydro One

We initially started using TapRooT® in 2002 in order to improve the quality…

Contact Us