Root Cause Analysis Blog


Monday Accident & Lesson Learned: Quick action by mother prevents toddler from falling through hole in moving train

Posted: February 19th, 2018 in Accidents, Investigations

A child was rescued from death when his mom grabbed him before he fell through a hole in a moving train.  In a 39-page report published by the Rail Accident Investigation Board, it was revealed that “The child entered the toilet, and as the door opened and the child stepped through it, he fell forward because the floor was missing in the compartment he had entered.” Read the report here.

Technically Speaking – The 2018 TapRooT® Global Summit is Right Around the Corner

Posted: February 16th, 2018 in Summit, TapRooT, Technically Speaking

The TapRooT® Support team is excited to remind you that the 2018 Global TapRooT® Summit is right around the corner with the Pre-Summit classes starting 2/26 and the Summit starting a couple days later on the 2/28. The Summit is a great way to improve your Root Cause Analysis skills, network with fellow TapRooT® users, and see how others use TapRooT® to help reduce the number of incidents at their company. We will have a table out in the Cumberland Concourse and we’d love for you to stop by and say hi!

You can register for the 2018 Global TapRooT® Summit and Pre-Summit here

Friday joke

Posted: February 16th, 2018 in Accidents, Jokes

Top 3 Reasons Corrective Actions Fail & What to Do About It

Posted: February 15th, 2018 in Accidents, investigation, Investigations, RCA Tip Videos, Root Cause Analysis Tips, Video, Video Depot

Ken Reed and Benna Dortch discuss the three top reasons corrective actions fail and how to overcome them. Don’t miss this informative video! It is a 15 minute investment of time that will change the way you think about implementing fixes and improve performance at your facility.

Frequently Asked Questions Page of the 2018 Global TapRooT® Summit Web Site

Posted: February 14th, 2018 in Summit

What are some of the most frequently asked questions about the Global TapRooT® Summit? See the FAQ page by clicking below.

Screen Shot 2018 01 15 at 4 43 28 PM

Support your Investigation Results with Solid Evidence Collection

Posted: February 13th, 2018 in Investigations, Summit

We have a couple of seats left in the “TapRooT® Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills” 2-day Pre-Summit course, February 26-27 in Knoxville, Tennessee. My co-instructor, Reb Brickey and I are excited to share methods of collection that will help you stop assumptions in their tracks!

Evidence collection techniques help investigators focus on the facts of an investigation. We will talk about pre-planning, different types of evidence to keep in mind as well as spend a good part of the second day learning about and practicing interviewing techniques. The course begins with an interesting case study and attendees break into investigation teams and work toward solving the evidence collection puzzle for the accident presented.

Class size is limited to ensure an ideal learning environment, so register now for the 2-day course only or for the 2-day course plus the 3-day Global TapRooT® Summit.


2018 Global TapRooT® Summit: The Secret Ninth Track

Posted: February 13th, 2018 in Summit

When you are choosing your track from the 8 learning tracks on the 2018 Global TapRooT® Summit schedule, you will notice that the very first option is “Alternative Sessions.”

Sometimes people wonder, “Is that the secret ninth track?”

Well… it could be.

Alternative sessions are best practice sessions that we think will appeal to our Summit attendees as a whole. So, you could sign up for the track as a whole. However, most people register for one of the eight tracks listed below it and then choose to switch a session or two with a session presented in Alternative Sessions. For example, if you registered for the Software Track but recently attended our TapRooT® VI Software Webinar (you clever Superuser you!), you may decide to spend your time in the Alternative Session “Making Sense of Complex Investigations” instead.

Alternative Sessions are options so you can fully customize your Summit track to be exactly what you want it to be. And who doesn’t love choices?

Do you have a question about customizing your Summit schedule so it’s a perfect fit? Give is a call at 865-539-2139 or send an email to

LEARN MORE about the 2018 Global TapRooT® Summit.

Gain Team Leader knowledge and experience in our 5-day training

Posted: February 13th, 2018 in Courses, TapRooT, Training

The 5-day training course is our “Team Leader” training course. This provides an expert level of knowledge on all of the TapRooT® techniques and on the TapRooT® Software. This course targets those investigators that will be system experts and team leaders and provides the knowledge to manage and utilize the TapRooT® process for any kind of investigation. TapRooT® Software is used throughout the 5 days. When leaving this training course, the investigator will have experience analyzing issues, performing interviews, leading an investigative team, and using the TapRooT® software as an aid and tool.

A great course that will expand your abilities to investigate.
The course not only looks at human performance but equipment failures as well.
~ R. Klahs

Register for an upcoming course:

Monterrey, Mexico – March 5

Charlotte, North Carolina – March 19

New Orleans, Lousiana – April 16

Edmonton, AB Canada – April 23

Las Vegas, Nevada – April 23


Join Us for Facebook Live, Wednesday, February 14 at Noon EST

Posted: February 13th, 2018 in Media Room, Topic of the Week

Why do we work so hard on root cause analysis? Because we want effective corrective actions! Join Ken Reed and Benna Dortch as they discuss innovative correction actions on Facebook Live.


When? Wednesday, February 14, 2018

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Stop Assumptions in Their Tracks!

Posted: February 13th, 2018 in investigation, Investigations, Root Cause Analysis Tips

Assumptions can cause investigators to reach unproven conclusions.

But investigators often make assumptions without even knowing that they were assuming.

So how do you stop assumptions in their tracks?

When you are drawing your SnapCharT®, you need to ask yourself …

How do I know that?

If you have two ways to verify an Event or a Condition, you probably have a FACT.

But if you have no ways to prove something … you have an assumption.

What if you only have one source of information? You have to evaluate the quality of the source.

What if one eye witness told you the information? Probably you should still consider it an assumption. Can you find physical evidence that provides a second source?

What if you just have one piece of physical evidence? You need to ask how certain you are that this piece of physical evidence can only have one meaning or one cause.

Dashed Boxes

Everything that can’t be proven to be a fact should be in a dashed box or dashed oval on your SnapCharT®. And on the boxes or ovals that you are certain about? List your evidence that proves they are facts.

Now you have stopped assumptions in their tracks!

Tips on Preventing Vibration in Rotating Equipment

Posted: February 13th, 2018 in Equipment/Equifactor®


Improper installation of rotating equipment, either for the first time or after maintenance, can quickly lead to excessive vibration and premature failure. Here are some tips on the proper use of shims and alignment equipment.

New TapRooT® Family Member

Posted: February 12th, 2018 in Current Events, Pictures

Sat hello to Lucy Belle … an 8 lb 8 oz girl.


Pass along congratulations to the proud mom, Amanda Biesbroeck (our Corporate Counsel) by leaving a comment below!

Career-Changing Learning Tracks at the 2018 Global TapRooT® Summit

Posted: February 12th, 2018 in Summit

The deadline to register is approaching!

Did you know we have 8 Learning Tracks at the 2018 Global TapRooT® Summit?

It’s not too late to register. View our short, informative videos and posts below and register for our February 26 event!

Asset Optimization

Human Factors


Patient Safety




Instructor Certification

The 2018 Global TapRooT® Summit will be held February 26 to March 2 in Knoxville, Tennessee.

Learn more.

Register today!

Career Opportunities for Candidates with TapRooT® Skills

Posted: February 12th, 2018 in Career Development, Job Postings


It takes less than 20 seconds for a hiring manager to make a decision about you based on your resume so make it stand out! Employers worldwide are interested in candidates with solid investigation and root cause analysis skills. Take your training and your record of improvements with you to your next interview. Here are some recent openings for candidates with TapRooT® root cause analysis skills:

Safety Advisor

HSE Site Supervisor

Safety Spc II – III

Lead Engineer – DOT Compliance

We have upcoming courses in these locations. Register today and advance your career!

Monterrey, Mexico, March 5, 2018, 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Lake Charles, LA, March 6, 2018, 2-Day TapRooT® Root Cause Analysis Training

Lisbon, Portugal, March 8, 2018, 2-Day TapRooT® Root Cause Analysis Training

Dubai, UAE, March 18, 2018, 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Charlotte, NC, March 19, 2018, 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Portland, OR, March 21, 2018, 2-Day TapRooT® Root Cause Analysis Training


2018 Global TapRooT® Summit Patient Safety Track

Posted: February 12th, 2018 in Best Practice Presentations, Best Practice Presenters, Medical/Healthcare, Summit

The Patient Safety Track is for healthcare professionals and those interested in healthcare. Michele Lindsay shares about what you can expect when you register for this informative track.

Register for the Patient Safety Track.

Learn more about the Summit.

Monday Accident & Lessons Learned: The Lac-Mégantic rail disaster

Posted: February 12th, 2018 in Accidents, Investigations

The Lac-Mégantic rail disaster occurred when an unattended 74-car freight train carrying Bakken Formation crude oil rolled down a 1.2% grade from Nantes and derailed, resulting in the fire and explosion of multiple tank cars. Forty-two people were confirmed dead, with five more missing and presumed dead. More than 30 buildings were destroyed. The death toll of 47 makes it the fourth-deadliest rail accident in Canadian history.


Click image to view or download .pdf


Carl Dixon returns to the 2018 Global TapRooT® Summit!

Posted: February 9th, 2018 in Current Events, Summit, TapRooT, Video

Carl Dixon, who sang and played with Coney Hatch, April Wine, and The Guess Who, is back at the 2018 Global TapRooT® Summit as the entertainment for our reception. Don’t miss the great music and good times!

Here’s a video from back in the day – Carl and Coney Hatch …

and April Wine …

And here is Carl in 2010 with the Guess Who …

And finally CARL SINGING “No Sugar” with The Guess Who in 2016 …

You’re Invited to Our 30th Anniversary Party!

Posted: February 9th, 2018 in Summit, TapRooT, Website Info and Updates

2018 marks an extremely special year for System Improvements Inc., it’s the year we turn 30. So come join us at the Knoxville Summit and help us celebrate three decades of saving lives!

The celebration will start Wednesday March 1 after the 4:00 pm session, and it will be located right outside the main session hall in the Cumberland Concourse. There will be appetizers, drinks, and Carl Dixon will be there for live entertainment.

Don’t forget to bring your tickets! Blue tickets will be distributed for a prize drawing, and you will receive orange tickets for two free drinks. So get ready to eat, drink, and be merry!

To learn more about the Summit click here or email me at Looking forward to seeing everyone soon.

Friday Joke

Posted: February 9th, 2018 in Accidents, Jokes

Technically Speaking – A look at Report Builder in TapRooT® VI

Posted: February 8th, 2018 in Software, Technical Support, Technically Speaking

Let’s take a quick look at the Report Builder in TapRooT® VI. We will look at some of the features and elements that can be added to your report in TapRooT® VI and how it can make your reports stand out. But first, I would like to show an example of a finished product then explain how we got the report and help you get an understanding of the different fields for your reports.


As you can see in the example there are a lot of things that can be shown on the report. The best thing is now you can Customize the report to show what you need it to.  Let’s start at the top of the report with the header. Here you are given the options to display your company’s logo and name, the title of the report and the date created (this is the day that the report is run).

In the report, we can use Visual Elements to make sections of your report stand out from the rest. Visual elements like images can have your report make a statement and show how extensive the incident actually was and make an impact when reporting to management. Through the report builder, you are given the option to insert either a large image or a small image like the one on the report example above. Other elements such as line breaks, lines, and page breaks will help you separate investigation information from other information gathered from Custom Tabs(Click here to learn about creating Custom Tabs).

As you can see we included a SnapCap into our report. Are you asking yourself, what is a SnapCap? A SnapCap is simply a SnapCharT® image capture that allows you to take an image of some part of your SnapCharT®. We included a SnapCap that shows our Sequence of Events in our report, but you are given the option to place other SnapCaps that may have been taken.


On the second page of our report, we added a table showing our Root Causes and Corrective Actions, grouped by Causal Factor. For your report, you can choose to show each individual fields such as Causal Factors, Root Causes, Generic Causes, Action Plans, and Tasks. Each one of these can be dragged and placed on the report individually in any order, but by choosing to have the table we create an organized view for presenting to the management team.

Other things that can be included in the report are attachments, Investigation Information and any information that was entered into Custom Tabs. Attachments can include pictures of the incident taken during the investigation. Investigation Information includes Name, Incident Date, Incident Time, Location and Classification (and anything else you want to add).

We’ve looked at the different types of information that can be added to your report and items that can make sections of your report stand out. The only thing left to do if for you to construct your own personalized report.

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!

How far away is death?

Posted: February 8th, 2018 in How Far Away Is Death?, Pictures

Screen Shot 2018 01 17 at 7 21 53 PM

Just one more ladder and …

Why You Should Use the TapRooT® Process for Smaller Investigations

Posted: February 7th, 2018 in Investigations, Root Cause Analysis Tips

“If the hammer is your only tool, all of your problems will start looking like nails.”

Per Ohstrom shares how TapRooT® is used to investigate smaller incidents by demonstrating the methodology. Are you using the 5-Whys to investigate these types of incidents? The 5-Whys won’t take you beyond your own knowledge. Find out how TapRooT® will!

Connect with Us

Filter News

Search News


Angie ComerAngie Comer


Anne RobertsAnne Roberts


Barb CarrBarb Carr

Editorial Director

Chris ValleeChris Vallee

Human Factors

Dan VerlindeDan Verlinde

VP, Software

Dave JanneyDave Janney

Safety & Quality

Garrett BoydGarrett Boyd

Technical Support

Ken ReedKen Reed

VP, Equifactor®

Linda UngerLinda Unger


Mark ParadiesMark Paradies

Creator of TapRooT®

Per OhstromPer Ohstrom

VP, Sales

Shaun BakerShaun Baker

Technical Support

Steve RaycraftSteve Raycraft

Technical Support

Wayne BrownWayne Brown

Technical Support

Success Stories

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

Hydro One

In 1995, BellSouth Telecommunications noticed an increase in the number of service interruptions or outages…

Bell South
Contact Us