Root Cause Analysis Blog


Job Postings for Candidates with TapRooT® Root Cause Analysis Skills

Posted: December 11th, 2017 in Career Development, Job Postings

Check out the career opportunities below for candidates with TapRooT® skills at facilities around the world

Get trained in 2017 to open up your job opportunities in 2018. Here are some recent postings looking for candidates with TapRooT® Root Cause Analysis skills:

EHS Manager

EHS Manager II

Patient Safety Program Coordinator

ESG Customer Quality Manager

Quality Manager

Quality Advisor

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

Join us LIVE on Facebook December 13

Posted: December 11th, 2017 in Media Room


Click image to go to our Facebook page.

Noon Eastern

11:00 a.m. Central

10:00 a.m. Mountain

9:00 a.m. Pacific


Santa Accidents 2

Posted: December 11th, 2017 in Current Events

My 20+ Year Relationship with 5-Why’s

Posted: December 11th, 2017 in Accidents, Career Development, Great Human Factors, Human Performance, Investigations, Performance Improvement, Quality, Root Cause Analysis Tips, Root Causes, TapRooT

I first heard of 5-Why’s over 20 years ago when I got my first job in Quality. I had no experience of any kind, I got the job because I worked with the Quality Manager’s wife in another department and she told him I was a good guy. True story…but that’s how things worked back then!

When I was first exposed to the 5-Why concept, it did not really make any sense to me; I could not understand how it actually could work, as it seemed like the only thing it revealed was the obvious. So, if it is obvious, why do I need it? That is a pretty good question from someone who did not know much at the time.

I dived into Quality and got all the certifications, went to all the classes and conferences, and helped my company build an industry leading program from the ground up. A recurring concept in the study and materials I was exposed to was 5-Why. I learned the “correct” way to do it. Now I understood it, but I still never thought it was a good way to find root causes.

I transferred to another division of the company to run their safety program. I did not know how to run a safety program – I did know all the rules, as I had been auditing them for years, but I really did not know how to run the program. But I did know quality, and those concepts helped me instill an improvement mindset in the leaders which we successfully applied to safety.

The first thing I did when I took the job was to look at the safety policies and procedures, and there it was; when you have an incident, “ask Why 5 times” to get your root cause! That was the extent of the guidance. So whatever random thought was your fifth Why would be the root cause on the report! The people using it had absolutely no idea how the concept worked or how to do it. And my review of old reports validated this. Since then I have realized this is a common theme with 5-Why’s; there is a very wide variation in the way it is used. I don’t believe it works particularly well even when used correctly, but it usually isn’t in my experience.

Since retiring from my career and coming to work with TapRooT®, I’ve had literally hundreds of conversations with colleagues, clients, and potential clients about 5-Why’s. I used to be somewhat soft when criticizing 5-Why’s and just try to help people understand why TapRooT® gets better results. Recently, I’ve started to take a more militant approach. Why? Because most of the people I talk to already know that 5-Why’s does not work well, but they still use it anyway (easier/cheaper/quicker)!

So it is time to take the gloves off; let’s not dance around this any longer. To quote Mark Paradies:
“5-Why’s is Root Cause Malpractice!”

To those that are still dug in and take offense, I do apologize! I can only share my experience.

For more information, here are some previous blog articles:

What’s Wrong With Cause-and-Effect, 5-Why’s, & Fault Trees

Comparing TapRooT® to Other Root Cause Tools

What’s Fundamentally Wrong with 5-Whys?

Monday Accident & Lesson Learned: Near Miss Incidents at Camden Junction South London

Posted: December 11th, 2017 in Accidents


The RAIB recently published an investigation report concerning track worker near miss incidents at Camden Junction South, London. Click here to view the report.

Dennis Osmer – RIP

Posted: December 8th, 2017 in Current Events, Meet Our Staff, Pictures


Dennis Osmer, 70, TapRooT® User/Instructor and safety and ergonomics expert died on December 1, 2017 from bladder cancer.

Dennis started using TapRooT® at Novartis and became the worldwide head of occupational health, safety, environment, and emergency management at CIBA Vision.

After he retired from CIBA Vision in 2008, he became a TapRooT® Instructor and for five years helped students learn to apply TapRooT® to improve safety and quality. In addition, he helped clients by facilitating difficult investigations to stop future safety issues.

Dennis was one of our first clients to show how TapRooT® could be used to investigate and prevent ergonomics issues while working for CIBA Vision. Here is a link to the success story that he presented at the Global TapRooT® Summit: This work saved many workers the pain and suffering from ergonomic injuries in the facilities customer support and distribution departments and saved the company over $6 million dollars in workers compensation costs in the six years after the program was implemented.

Some people just have an ability to make positive change happen and Dennis was one of those people. Everyone here at System Improvements and all of his students and co-workers, as well as his family, will miss him.

See this link:, for his obituary and memorial.

Advance the Quality of your Risk Assessments: A Q & A with Jim Whiting

Posted: December 8th, 2017 in Summit

Would you like to add “RA Workshop facilitator” to your resume? Are you interested in improving your current risk matrix tool in a way that achieves dramatic results? We were excited to talk to Jim Whiting about his upcoming Risk Management – Best Practices & Risk-Based Thinking course, at the 2018 Global TapRooT® Summit, February 26-27, 2018 in Knoxville, Tennessee and learn that these objectives are within your reach.

Q:  What are the main benefits of attending this course for a newcomer or a very experienced professional?

A: Regardless of your current level of experience, the main benefit you will gain is learning how to use and adapt new practical and effective RM approaches, methods and tools which are now required in managing all types of risk in general, and particularly as specified in new HSEQ System Standards.

Q. What is an example of one such approach that I could learn & derive benefit?

A: The workshop training will describe and provide hands-on practice with a proven Likelihood Estimation Guidance tool which significantly reduces variability of risk assessors’ estimates of the likelihood / probability / frequency of any specific risk scenario. After the workshop, the 100’s of past attendees describe how they are much more confident of the consistency and accuracy of likelihood estimation and hence risk assessments.

Q: Why do Risk Assessments always seem to be very subjective and depend on personal opinions, biases and perceptions?

A: YES many risk assessments in the past have led to widely variable estimates of risk which then cannot help in our HSEQ decision making. That is why the Workshop concentrates on improved facilitation techniques which minimize the effects of those factors. You will learn how to become a very effective RA Workshop facilitator.

Q: What are some examples of these improved facilitation techniques?

A: To achieve better results from a RA team, you will learn about optimizing control and design of facilitation factors such as number, composition, types, profiles, interpersonal dynamics and consensus techniques including the Delphi technique.

Q: What are other beneficial take-aways from the training?

A: You will learn how to avoid common RM traps such as – arguing unnecessarily about consequence severity; mixing different scenarios and attempting to assess them together at the one time; misinterpretation of effective applications of the Hierarchy of Risk Controls; not using formal criteria for making consistent decisions re risk tolerability; not recognizing when everyday risk mythology is influencing assessments; etc.

Q: Can I get a better understanding of RBT Risk Based Thinking and what I would need to do to conform with RBT aspects of ISO / ANSI Standards?

A: A significant issue covered in the workshop is how to clarify the degree of formality of RM processes and tools needed to conform with RBT requirements of ISO Management System Standards 9001, 14001 and the new OHSMS ISO 45001.

Q: Can I learn how to make our current risk matrix work better and more effectively without major changes?

A: Many past attendees were pleased that they were shown how to consider dramatic improvements to their existing risk matrix tool without necessarily complete replacement and the often accompanying trauma of major change.

We’re looking forward to Jim Whiting sharing all these valuable risk management best practices at the 2018 Global TapRooT® Summit!

CLICK HERE to learn more 









Friday Joke: Nuclear Winter Wonderland

Posted: December 8th, 2017 in Documents, Jokes, Video

Winter wonderland

Click on the links below for a Nuclear Winter Wonderland (either a Quicktime movie or a PowerPoint)

Nuclear Winter Wonderland


The PPTX is the best quality.

Or try this YouTube video…


TapRooT® Certified Instructor Recertification Track

Posted: December 7th, 2017 in Summit

Certified TapRooT® Instructors: Your 2018 Summit attendance is required!


It is time to renew your Certification status so that you can continue teaching TapRooT® within your company. Join Linda, Ken and Michelle as they answer your questions and provide important information about changes and new TapRooT® products. Most importantly, your certification status will be extended for two more years.

Here’s what you can expect:

10 2-day Pre-Summit courses to choose from and expand your knowledge.

8 Best Practice Sessions

  1. TapRooT® Users Share Best Practices, Linda Unger, Michelle Wishoun & Benna Dortch
  2. Defining Better Causal Factors, Ken Turnbull
  3. What’s New in TapRooT® Software, Dan Verlinde
  4. TapRooT® Certified Instructor Recertification Workshop, Ken Reed, Linda Unger, Michelle Wishoun
  5. Top 7 Secrets of a Great Investigation Interview, Barb Carr
  6. Taking Your Investigation Communication Skills to a Dynamic New Level, Vincent Phillips
  7. Best Practices for Sharing Lessons Learned, Pat Fortune
  8. Performance Improvement Gap Analysis


Software Track at the 2018 Global TapRooT® Summit

Posted: December 7th, 2017 in Best Practice Presentations, Best Practice Presenters, Current Events, Software, Summit, Uncategorized


We’re getting closer to the 2018 Summit in our hometown of Knoxville, TN on February 28th -March 2nd (Pre-summit courses February 26th-27th)!

Here’s what you can look forward to in our Software Track sessions:

The TapRooT® Software Sandbox – Dan Verlinde and Angie Comer

In this session, you will have access to the latest TapRooT® VI Software and have an opportunity to navigate throughout the application. You can ask questions and learn tips and tricks from the designer of the software himself!

Instructor Software Updates – Dan Verlinde and Ken Reed

This session is intended for certified TapRooT® Instructors and will provide important updates and information on the software.

What’s New in TapRooT® Software – Dan Verlinde

Learn what’s new in the TapRooT® Software and get a sneak peek at what’s coming soon in 2018!

Building Your Software Incident Report – Dan Verlinde

In this session, you will learn how to create customized reports and templates in the software that you can easily use to effectively share your incident, investigation and audit findings with others.

Software Advisory Board – Dan Verlinde (and Software Advisory Board Members)

A discussion on current software topics will be held in this session with members of the Software Advisory Board.

What is a Trend and How Can You Find Trends in the TapRooT® Data – Chris Vallee

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.

Best Practices for Sharing Lessons Learned – Pat Fortune

Learn best practices for sharing lessons learned from an experienced TapRooT® Investigator.

Performance Improvement Gap Analysis – TapRooT® Instructor Team

Meet with other TapRooT® users from world leading companies and discuss lessons learned, best practices and favorite takeaways that you can apply to your business and share with team members once you leave the summit.

And of course, all tracks attend the inspiring KEYNOTE SPEAKER sessions.

Also, don’t miss a chance to learn even MORE about the software in our Pre-Summit, Getting the Most from Your TapRooT® VI Software course.

We can’t wait to see you there! To register for the Summit, click HERE.

Fake News or Real?

Posted: December 6th, 2017 in Accidents, Current Events, How Far Away Is Death?, Human Performance, Investigations, Pictures, TapRooT


That’s the headline. Here is the link:

Could it really be true? I guess the funeral home industry needs TapRooT®!

(Editor’s update: After this post was published, Snopes reported this as fake news and the news story was removed. Thank goodness!)

This is “National Hand Washing Awareness Week”

Posted: December 6th, 2017 in Current Events, Medical/Healthcare, Pictures

Want to prevent infections? Wash your hands!


A press release from the Henry the Hand Foundation

National Handwashing Awareness Week Dec 3-9, 2017

In a recent article in New England Journal of Medicine  “Chasing Seasonal Influenza”  it was reported …according to the Australian Government Department of Health. Influenza A (H3N2) viruses predominated, and the preliminary estimate of vaccine effectiveness against influenza A (H3N2) was only 10%. The implications for the Northern Hemisphere are not clear, but it is of note that the vaccine for this upcoming season has the same composition as that used in the Southern Hemisphere.

BUT, No need to worry because in 1999 during first Flu vaccine shortage a community wide coalition created events promoting handwashing with coloring contests throughout schools and community centers and ended during the first National Handwashing Awareness Week! Result was one of the healthiest year for our community!


Share the National Handwashing Awareness Week poster with everyone you believe could benefit!! And an additional bonus is True Flu Prevention poster for those who do NOT want the flu or flu-like illness!!

Our latest innovation is the first portable self teaching Hand Hygiene Learning Center that helps students train themselves. Sized for Early Childhood age group and one for larger students, as well! Put it outside the Classroom, in the cafeteria, playground or wherever there may a norovirus/shigella outbreak!

There is a Classroom Tool Kit included to help your students sustain the habit! The addition of the Tool Kit can help train your staff, students and their families with the tools to keep them healthy year round by practicing Henry the Hand’s 4 Principles of Hand Awareness.

The BEST science-based, multi sensory curriculum in a Tool Kit that is so easy to understand it teaches itself! Your gift for Global Handwashing Day!!

In the  Science of Habit, Dr Jelena Vujcic discusses the two critical components around habit : first, creating a good habit and second, is sustaining the habit. However, sustaining the habit is the more difficult component to achieve!

Visit the Henry the Hand Website.

Trending without Purpose just Creates “Big Clumsy Data”

Posted: December 6th, 2017 in Summit, Training

As a TapRooT® Root Cause Analysis Instructor and person with a continuous improvement background, I often hear these questions when teaching …

“We collect lots of data, what should we be looking for?” STOP

“How do we link what we changed to if it worked?” STOP

“What would you define as a significant change?” STOP

STOP and go back 20 steps to figure out what is truly important to know …

  1. What does successful mean in numbers?
  1. Could you measure what is important today with the numbers you currently collect?
  1. What numbers should be tracked that would alert you that you must act now?
  1. What do you need to do to establish and track effective/ineffective change?
  1. What do you need to be able to do translate the numbers collected into a deliverable message to leadership and the frontline workers?
  1. Who should be inputting the daily numbers and who should be reviewing the numbers?

At the end of the day for whatever task that you are required to perform successfully, you should be able to …

  1. Prove based on reality in numbers that you have been successful.
  1. Be able to refute bad numbers that do not represent reality… no matter who made the chart.

Here are numbers with purpose …

  1. We offer our 2-Day Advanced Trending Techniques Course as a public course once a year as a Pre-Summit Course. Next year it’s scheduled for February 26-27, 2018
  1. In many cases there are only 2 or 3 of you at your company that need to run the numbers. This saves the company money to go to our Pre-Summit Course instead of setting up an Onsite Course.
  1. There will be 10-20 other attendees from other companies to talk bad numbers and good numbers. You will learn from each other.

Kevin McManus and I look forward to seeing you our Pre-Summit Trending Course.

Not Near-Misses … They Are Precursors

Posted: December 5th, 2017 in Investigations, Performance Improvement, Root Cause Analysis Tips

I had an epiphany today.

Have you ever noticed how management doesn’t take near-miss incidents seriously? They don’t see them as just one step away from a fatality?

I think part of the problem may be the terminology.

Near-miss just doesn’t sound very serious. After all … it was a miss.

But what if we called these incidents PRECURSORS.

A precursor tells you that something IS going to happen unless you change.

If management saw these incidents as an indicator that something was GOING TO HAPPEN, then, maybe, they would take action.

You may have already thought of this and changed the language that you use around incidents … but I haven’t seen the words PRECURSOR INCIDENTS used very often. Now may be the time to start.

One more thing … Precursor Incidents mean that incidents that could not cause an accident ARE NOT precursors. Thus, paper cuts are not precursors of amputations.

Therefore, we can stop wasting our time investigating incidents that will never cause a serious injury.

Just a thought…

Santa Accidents 1

Posted: December 4th, 2017 in Current Events

Monday Accident & Lessons Learned: Firm fined after worker severs fingers

Posted: December 4th, 2017 in Accidents

An employee lost four fingers, broke several bones and dislocated his wrist cleaning steel shafts on a metal working lathe. The investigation found that the company did not ensure the work was carried out safely.  Read the story here.

Avoid scenarios like this by conducting proactive root cause analysis investigations. Protect your people from life-changing injuries that can be avoided. Click here for a list of our upcoming 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Trainings that include training on the proactive use of TapRooT®.

Join us LIVE on Facebook, Wednesday, December 6 at Noon Eastern

Posted: December 2nd, 2017 in Career Development, Investigations, Media Room


Click image to go to our Facebook page.

Noon Eastern

11:00 a.m. Central

10:00 a.m. Mountain

9:00 a.m. Pacific

December 6: Join Mark Paradies as he discusses the Human Factors Best Practice Track at the 2018 Global TapRooT® Summit!

OSHA Top 10 Violations

Posted: December 1st, 2017 in Accidents

TapRooT® Root Cause Analysis can help with hazard prevention and control.

Sign up for training and learn how to avoid incidents, minimize risks and provide workers with safe working conditions.

Technically Speaking – Custom Banner and Report Images

Posted: November 30th, 2017 in Technical Support, Technically Speaking, Video, Video Depot

Here is a look at how to add custom images to your TapRooT® VI banner and reports.

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, it doesn’t mean it has to be complicated!

Job Postings for Candidates with TapRooT® Skills

Posted: November 30th, 2017 in Career Development, Job Postings


Time is running out! Get trained in 2017 to open up your job opportunities in 2018. Here are some recent postings looking for candidates with TapRooT® Root Cause Analysis skills:

Reliability Engineering Supervisor

Associate-Senior Engineer (Electrical) Nuclear

Patient Safety Assistant Coordinator (PSAC)

Health & Safety (QHSSE) Advisor

Quality Advisor

There are still opportunities for Root Cause Analysis Training in 2017 or in January 2018!

December 11: Houston, Texas 5-Day

December 12: Sao Paulo, Brazil 2-Day

December 13: Bogota, Colombia 3-Day  (add one day of equipment troubleshooting December 15)

December 14: Perth, Australia 2-Day

January 11: Perth Australia 2-day

January 18: Houston 2-Day

January 24: New Orleans, Louisiana 2-Day

January 29: San Antonio, Texas 5-Day





TapRooT® 2 Day in the Music City

Posted: November 29th, 2017 in Uncategorized

We are having a wonderful 2 Day course in the museum of the 21c Hotel in Nashville. One of the art installations (pictured below) pokes fun at a BAD safeguard. Our students will be able to write a Corrective Action for this by the end of the day!

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