Root Cause Analysis Blog


Asset Optimization Track at the Summit – Are you in?

Posted: January 2nd, 2018 in Equipment/Equifactor®, Summit

If you are a typical procrastinator, you probably haven’t signed up for the Global TapRooT® Summit yet. Well, it’s now 2018, and procrastination is over! Don’t miss the chance to get in on one of the best opportunities to improve your company.

I wanted to give you a little more information about one of the most exciting tracks at the Summit: the Asset Optimization Track (doesn’t that sound so much better than “Equipment Fixing Track”?) We’ll be providing some great sessions to get your reliability and maintenance processes moving in the right direction in 2018. Besides the Summit Keynote addresses common to all tracks, here are a few of the sessions that make the Asset Optimization track right for you:

  • Multiple Failures Without Learning:  Tired of repeat failures?  Chris Vallee will give you some examples of why the “break it – Fix it” mentality is no longer the way to go.
  • Improved maintenance Troubleshooting using Equifactor®:  I’ll be leading a session on how Equifactor® Equipment Troubleshooting module of the TapRooT® VI software service works, including some of the new features available in the software.  For some reason, I think this is the best session of all!
  • The Business End of Equipment Reliability:  OK, maybe my session is NOT the best!  Heinz Bloch will be with us again this year, giving us his unique insight into the business case behind reliably operating your equipment.
  • The Psychology of Failing Fixes:  Kevin McManus will be sharing his unique view on how root cause analysis is the key to a truly reliable operation.  Don’t miss the opportunity to soak up some of Kevin’s enthusiasm!

We’re going to have a great Summit this year, in our hometown for the first time ever.  Please plan on signing up for the Summit.  Don’t tell yourself, “Oh, yeah, I need to do that sometime.”  The time is now; the Summit is next month! REGISTER NOW for the Asset Optimization Track!

Resolve to Improve!

Posted: January 2nd, 2018 in Current Events, Performance Improvement, Pictures, Summit, TapRooT


On New Year’s Eve, did you make a resolution? According to the data company, iQuanti, here were the top seven resolutions made:

  1. Get healthy.
  2. Get organized.
  3. Live life to the fullest.
  4. Learn new hobbies.
  5. Spend less/save more.
  6. Travel.
  7. Read more.

Are you surprised by any of the above? Nothing earth shattering there.  Outside personal improvements, there is a way to truly make a difference in your own life as well as the lives of others. The one resolution not on the top seven list that you shouldn’t overlook is a work-related resolution.

Here are some work-related resolutions to consider…

  • Eliminate the blame environment when someone makes a mistake.
  • Stop problems from happening over and over again.
  • Save time and get better results when you perform an incident investigation.
  • Learn best practices to make your workplace safer and more productive.
  • Become better at your job by applying state-of-the-art root cause analysis.

How do you do these things?


Start by attending TapRooT® Training. See our upcoming courses here:

Then make sure that you are at the 2018 Global TapRooT® Summit to learn best practices from around the world. That’s the best place to learn best practices from industry leaders from around the world. The Summit is in Knoxville, TN, on February 26 – March 2. See the Summit schedule here:

And register here:

The knowledge you will gain will help you make 2018 the best year ever.

Job postings

Posted: January 1st, 2018 in Career Development

Discover the career opportunities below for candidates with TapRooT® skills at facilities around the world.

Get trained soon to open up your job opportunities for the new year. Here are some recent postings looking for candidates with TapRooT® Root Cause Analysis skills:

Health & Safety Specialist/Engineer/Advisor
Reliability Engineering Supervisor
Field Service Manager
EHS Manager II
Process Safety Specialist
Quality Advisor

Check out our complete listing of 2-day TapRooT® trainings around the world here and register today!

Friday Joke

Posted: December 29th, 2017 in Jokes

Technically Speaking – Helpdesk Humor

Posted: December 28th, 2017 in Software, Technical Support, Technically Speaking

Special thanks to all the IT professionals who held emergency support sessions from their relatives WiFi over the holidays!  

Happy Holidays and may you find time to rest well in 2018!

 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!

5 Day TapRooT® course in Dubai – time to register!

Posted: December 27th, 2017 in Courses

Our last course filled several weeks in advance and had a very long waiting list. The next course will be on March 18, so don’t delay.

To avoid disappointment, please register right away! You can register HERE

I look forward to seeing you in Dubai!

Take some time off!

Posted: December 26th, 2017 in Pictures

Each week I try to write something engaging about root cause analysis, incident investigation, or performance improvement.

This week I’m taking some time off to be with the family.

I suggest you do the same.

  • Stop responding to electronics.
  • Stop reading e-mails.
  • Put your cell phone on do not disturb.

Live in the minute and enjoy those around you for one week.

Then you can get back to the grind of making your company excellent.

Best Regards!


Monday Accident & Lesson Learned

Posted: December 25th, 2017 in Accidents, Root Causes

In Singapore, a car was crushed by two trailers after a passenger bus hit the one behind him, causing a chain collision that left 26 people injured. Read more here.

Merry Christmas!

Posted: December 25th, 2017 in Current Events


Friday Joke

Posted: December 22nd, 2017 in Accidents, Jokes

‘See, I told you we could make it under that bridge!’

The Georgia State Public Services Commission Demands Root Cause Analysis of Atlanta Airport Blackout

Posted: December 21st, 2017 in Accidents, Current Events, Equipment/Equifactor®, Investigations, Pictures


Read about the story in The Atlanta Journal-Constitution:

It’s hard to believe there wasn’t a redundant transmission line and transformers to such a vital resource.

Technically Speaking – Happy Holidays

Posted: December 21st, 2017 in Software, Technical Support, Technically Speaking

Here at TapRooT® Technical Support, we wanted to wish all our clients a Happy Holidays! We will be out of the office Monday and Tuesday but will be back ready to go on Wednesday morning. We are grateful for all our U.S. and global clients and look forward to connecting with you next week!

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!

2018 Global TapRooT® Summit Updates!

Posted: December 19th, 2017 in Best Practice Presentations, Best Practice Presenters, Summit

There’s been LOTS of exciting news posted lately about the upcoming 2018 Global TapRooT® Summit, so I thought I’d organize it all into one post and help you catch up.

There are NINE Best Practice Tracks you can choose from for your Summit experience (February 28 – March 2):

  1. Human Factors
  2. Investigator
  3. Quality
  4. Safety
  5. Software
  6. TapRooT® Instructor Recertification
  7. Alternative Sessions (More info to come in January)
  8. Asset Optimization
  9. Patient Safety (More info to come in January)

There are TEN 2-day Pre-Summit Courses for you to choose from (February 26 – 27)

  1. TapRooT® Root Cause Analysis Training (Course description)
  2. Equifactor® Equipment Troubleshooting and Root Cause Analysis (Course description)
  3. Advanced Causal Factor Development Course (Course description)
  4. Advanced Trending Techniques (Recent update! | Course description)
  5. TapRooT® Analyzing and Fixing Safety Culture Issues (Recent update! | Course description)
  6. Risk Management – Best Practices & Risk-Based Thinking (Recent update! | Course description)
  7. Getting the Most from Your TapRooT® VI Software (Recent update!Course description)
  8. TapRooT® for Audits (Recent update! | Course description)
  9. TapRooT® Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills (Recent update! | Course description)
  10. Understanding and Stopping Human Error (Recent update! | Course description)

Make plans to attend the Reception with Carl Dixon.

And don’t forget to check out the recently updated Hotel & Travel page for ideas about:

  • where to stay.
  • how to get around Knoxville once you arrive (“Transportation Tips”).
  • what’s happening around town that you may be interested in during your free time.

And CLICK HERE to view our informative short Summit videos.


Sign up now for the February 2018 Global TapRooT® Summit Quality Track

Posted: December 19th, 2017 in Best Practice Presentations, Best Practice Presenters, Quality, Summit, TapRooT


Need a jumpstart on your Quality Management System’s improvements to better utilize your company’s product realization? Sign up for the Quality Track during the Global TapRooT® Summit, Knoxville, Tennessee, February 26 – March 2, 2018

Improve Your Resource Usage Management by attending:

Mark Paradies (the creator of TapRooT®)

How to Replace 5 Whys with TapRooT® for Better Results

People argue that 5-Whys is a “good enough” root cause analysis tool. They say it’s simple to ask “why” five times and that people in the field can “understand it.” Well, the time has come to put that argument to bed… 5-Whys is inadequate. It has fundamental flaws that make it inadequate. This session will demonstrate how replacing 5-Whys with TapRooT® provides better results.


Kevin McManus– Great Systems!

Stop Daily Goofs for Good

This session has a proactive, process-based focus, and promotes the use of systematic improvements to prevent human error and improve cognitive ergonomics on the job.

Using Wearables to Minimize Daily Human Errors

Look at how wearables are being used both now and in the future to help prevent errors and identify problems more effectively.


Barb Carr – System Improvements, Inc.

Top 7 Secrets of a Great Investigation Interview

Take your interviewing skills to the next level and collect better quality and quantity of information from your investigative interviews by harnessing the power of the seven secrets.


Improve Your Management Responsibility by attending:

 John Boyle

Making Audits an Integral Part of a Proactive Improvement Program –

This session has a proactive, process-based focus, and promotes the use of systematic improvements to prevent human error and improve cognitive ergonomics on the job. Kevin McManus

 Jonathan Kennedy

Influencing Change

Nothing happens without change. Nothing happens without support of change. Learn techniques to increase the ability to change with full management support.


Improve Your Analysis and Improvements by attending:

Christopher Vallee – System Improvements, Inc.

What is a Trend and How Can You Find Trends in the TapRooT® Data?

You have invested in TapRooT® and have root cause data, but do you know what the data tells you? Do you know if what you are measuring has changed for the good or the bad? Do you know how to access your trend-able data in your VI Software? Learn what to look for, what needs to be acted on and how to access the data on VI Software.

Performance Improvement Gap Analysis

Put together everything that you learned this week in your Summit Tracks and from your peers, then develop your action plan to hit the ground running.


Learn more!

Are you interested in improving human performance? Try this four step plan!

Posted: December 19th, 2017 in Courses, Great Human Factors, Human Performance, Performance Improvement, Pictures, Summit


Is discipline the main way you “fix” human error problems?

Are you frustrated because people make the same kind of mistakes over and over again?

Have you tried “standard” techniques for improving human performance and found that they just don’t get the job done long term (they have an impact short term but not long term)?

Is management grasping for solutions to human error issues?

Would you like to learn best practices from industry human performance experts?

Try this four step plan:


1. Attend a 5-Day TapRooT® Advanced Root Cause Analysis Course.

The TapRoot® System is made to reactively and proactively help you solve human performance issues. It has built in human factors expert systems that guide you to the root causes of human errors and help you develop effective fixes. The 5-Day TapRooT® Course is the best way to learn the system and get started fixing human performance issues.

See the upcoming course schedule here:


2. Attend the Understanding and Stopping Human Error Course

At this two day class, Dr. Joel Haight, a human factors and safety improvement expert and industrial engineering professor at the University of Pittsburg (where he is the Director of the Safety Engineering Program) shares the reasons why people make mistakes and what you can do to understand the problems and fix them.

Joel is an expert TapRooT® User having extensive experience apply TapRooT® to fix human factors problems at a Chevron refinery and in the oil field in Kazakhstan. He is also an expert in applying other human performance analysis and improvement techniques. He brings this knowledge to the 2-Day Understanding and Stopping Human Error Course.

It is best if you have already attended at least a 2-Day TapRooT® Course prior to attending this course. See the course description here:


3. Attend the Human Factors Track at the 2018 Global TapRooT® Summit

Once a year we put together a track at the Global TapRooT® Summit that is designed to share best practices and the latest state-of-the-art techniques to improve human performance. That’s what you get at the Human Factor Track at the Summit. What are the sessions at the 2018 Global TapRooT® Summit?

  • TapRooT® Users Share Best Practices – This is a workshop designed to promote the sharing of investigation, root cause analysis, and human performance best practices from TapRooT® Users from around the world. Every year I attend this session and get new ideas that I share with others to help improve performance. Many say this is the best session at the Summit because they get such great ideas and develop new, helpful contacts from many different industries.
  • Top 5 Reasons for Human Error and How to Stop Them – Mark Paradies, President of System Improvements and a human factors expert, shares his deep knowledge of the top five reasons that he see’s for people making “human errors.” For each of these he shares his best ideas to stop the problems in their tracks.
  • Stop Daily Goofs for Good – Kevin McManus, a TapRooT® Instructor and performance improvement expert, shares systematic improvement ideas s to prevent human error and improve cognitive ergonomics on the job.
  • Using Wearables to Minimize Daily Human Errors – Using “wearables” is a technological approach to error prevention. Find out more about how it is being used and may be applied even more effectively in the future.
  • Alarm Management, Signal Detection Theory, and Decision Making – Are people at your facility overwhelmed by alarms? Do the become complacent because of nuisance alarms? Dr. Joel Haight, Director of the University of Pittsburg Safety Engineering Program will discuss control system decisions, decision execution, alarm management, signal detection theory, and decision making theory and how it could be critical in an emergency situation.
  • The Psychology of Failing Fixes – Why do your fixes fail to prevent human error? That’s what this session is all about!
  • What is a Trend and How Can You Find Trends in the TapRooT® Data? – looking for trends in human error data is an important activity to identify generic human factors problems and take the first step to major human performance improvements. Now for the bad news. Most people really don’t understand trending. Find out what you need to know and how to put trending to work in your improvement program.
  • Performance Improvement Gap Analysis – This is the session where you put everything together. Where does your program have holes? How can you apply what you have learned to fill those holes? What are others doing to solve similar problems? Put your plan together so you are ready to hit the ground running and make improvements happen when you get back to work.

And the Best Practice Sessions outlined above are only a start. You will also see five great Keynote Speakers:


Mike Williams will share his experience surviving the Deepwater Horizon explosion.


Dr. Carol Gunn will share the story of the her sisters unnecessary death in a hospital and patient safety improvement.


Inky Johnson will share his experience with a debilitating football injury and how it changed his life and helps him inspire excellence in others.


Mark Paradies will help you get the most out of your application of TapRooT®.


Vincent Ivan Phipps will teach yo to amplify your leadership skills and communication ability.

We know that the Summit will provide you with new ideas and the inspiration to implement them.


4. Get started! Analyze your human performance issues and make improvements happen!

Just Do It! get back to work and implement what you have learned. Need more help? We can provide training at your site to get more people trained in using TapRooT® so that you have help making change happen.

Don’t wait! Get your four step plan started! Register for the courses and Summit today!

5 Reasons Why You Should Attend the Pre-Summit Course: Getting the Most from Your TapRooT® VI Software

Posted: December 19th, 2017 in Software, Summit, Uncategorized


  1. Learn to create your own Custom Tab and Custom Fields. Creating custom tabs and fields is a very powerful feature in the software and this course will go into great detail on how to customize these for your business needs.
  2. Learn to create your own Custom Reports and Report Templates. The TapRooT® VI software does not assume to know exactly what reports you want to see and share with your team members. This course will teach you how to build reports that contain specifically what you want and how to create and share the same templates with other users.
  3. Learn to use the redesigned Optional Techniques. Do you know that the software contains tools and techniques that can help you build better SnapCharT®s and more thoroughly investigate your incidents? This course will show you how to use Safeguard Analysis, Change Analysis, Equifactor® and CHAP.
  4. Learn the Administrative functions available to give your users more options. This course will go into great detail on the new administrative features including Notifications, Maintenance Mode and Custom Equifactor®.
  5. Learn how to use the Trending features to understand where opportunities exist in your business. The new dashboard is customizable and offers hundreds of options to look at root cause, location and classification trends. You will also learn to export custom data to create additional custom reports.

Come join us February 26th and 27th before the Global TapRooT® Summit to get the most from your TapRooT® VI Software!

CLICK HERE to register today.

Hack of safety system causes plant shutdown …

Posted: December 18th, 2017 in Accidents, Current Events, Investigations, Uncategorized

Jim Whiting (TapRooT® Instructor) sent me this link to a plant shutdown caused by a hack of a safety system computer code.

There isn’t a lot of specifics in the article but it does make one wonder about the applicable corrective actions and how they should be applied across the whole industry.

Sign up now for the Investigator Best Practices 2018 Summit Track

Posted: December 18th, 2017 in Best Practice Presentations, Best Practice Presenters, Summit

The 2018 TapRooT® Summit will be in Knoxville, TN February 28 – March 2, with unique and valuable Pre-summit courses on February 26 and 27. Make plans to attend, and sign up early since this will be a blockbuster!

As the coordinator for the Investigator Best Practices Track, I’d like to introduce the speakers and best practice sessions.

How to Replace 5 Whys with TapRooT® for Better Results – Mark Paradies (the founder of TapRooT®)
This session will demonstrate how replacing 5-Whys with TapRooT® provides better results. It is a misconception that 5-Whys is “good enough” for root cause analysis. It has fundamental flaws, not least of which is that it introduces investigator bias. TapRooT® will yield better results also in complex, but also in smaller investigations.

Improving Safety Culture through measuring and grading investigations – Jack Frost (VP Matrix Service, contractor to energy, power and manufacturing)
Continuous improvement is important not just in production but also with the HSEQ efforts. In this session Jack Frost will share how a disciplined approach to incident investigations over three years has improved performance more than 40%, and improved the safety culture in an organization. Central to the approach has been a focus on engineering controls, quality assurance of investigations, and use of KPIs for personal accountability and rewards.

Making sense of complex investigations– Pat Fortune (team lead for EH&S major projects at Suncor Energy)
Pat is an “investigator’s investigator” with dozens of years of experience. He will warn us not to go down the wrong track with investigations, not take shortcuts but be disciplined and use the expertise built into the Root Cause Tree®

Best practices for sharing lessons learned – Pat Fortune
This session focuses on Pat’s take on “the learning organization”, that does investigations of incidents and near misses but also broadly communicates results internally. You will greatly benefit from making this approach part of your company DNA.

The psychology of failing fixes – Kevin McManus (Author and trainer with 35 years experience with Engineering, Training, and as a Plant Manager and Director of Quality)
This will be a top session on understanding the psychology behind insufficient fixes. Learn how blaming individuals and mis-identifying systemic root causes can lead to failing corrective actions

Top 7 secrets of a great investigation interview – Barbara Carr (TapRooT® trainer and co- author of the new book “Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills”)
There are certain techniques and approaches that are proven to work well when doing investigative interviews. Come learn how to collect better quality and quantity of information from people you talk to.

Deep Dive into the Procedures Basic Cause Category – Dr. Ralph Brickey (TapRooT® trainer with a 28 year background in nuclear power maintenance, training and program management)

An investigator looking at an incident may find that performance would have improved if a well-written procedure was used correctly. This Basic Cause category deals with instances where a procedure was not followed, was wrong, or followed incorrectly. Learn what a good procedure looks like, and what pitfalls exist with obsolete or poorly written ones. Ralph will make sure this is a lively and interactive session, as he “is curious about almost everything and interested in the rest.”

Participants in this eminent track will of course also have opportunity to hear the different keynote addresses. Feel free to contact me with questions, and register today!

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