Root Cause Analysis Blog


Testimonial Tuesday

Posted: March 13th, 2018 in Courses, Testimonials

If you have attend one of courses or a TapRooT® Summit at some point you’ve probably been asked to give a testimonial or filled out one of our course evaluations. We take your feedback seriously. So, thank you for helping us grow and improve.

Read what people have to say about our new Corrective Action Helper®.

  • “The book Corrective Action Helper® is a very good quick line for C.A. in general.” – W. Wiech
  • “The Corrective Action Helper® guide will certainly prove valuable.” – Terry Fisher

Read what benefits people received from attending our 2-Day Training Course.

  • “Gives you the ability to remove bias out.” – Jackie Nippard
  • “I see myself improving on the entire II process and I now have the tools to improve.” – Mark
  • “I have a better perspective of the details that contribute to incidents.” – Waylon Munch

Hire a Professional

Posted: March 12th, 2018 in Accidents, Career Development Tips, Performance Improvement, Training

root cause analysis, RCA, investigation

I know every company is trying to do the best they can with the resources that are available. We ask a lot of our employees and managers, trying to be as efficient as we can.

However, sometimes we need to recognize when we need additional expertise to solve a particular problem. Or, alternatively, we need to ensure that our people have the tools they need to properly perform their job functions.  Companies do this for many job descriptions:

  • Oil analyst
  • Design engineer
  • Nurse
  • Aircraft Mechanic

I don’t think we would ask our Safety Manager to repair a jet engine.  THAT would be silly!

However, for some reason, many companies think that it is OK to ask their aircraft mechanics to perform a root cause analysis without giving them any additional training.  “Looks like we had a problem with that 737 yesterday.  Joe, go investigate that and let me know what you find.”  Why would we expect Joe, who is an excellent mechanic, to be able to perform a professional root cause analysis without being properly trained?  Would we send our Safety Manager out to repair a jet engine?

It might be tempting to assume that performing an RCA is “easy,” and therefore does not require professional training.  This is somewhat true.  It is easy to perform bad RCA’s without professional training.  While performing effective  investigations does not require years of training, there is a certain minimum competency you should expect from your team, and it is not fair to them to throw them into a situation which they are not trained to handle.

Ensure you are giving your team the support they need by giving them the training required to perform excellent investigations.  A 2-Day TapRooT® Essential Techniques Course is probably all your people will need to perform investigations with terrific results.


Amplify Your Presentations by Adapting to Your Audiences

Posted: March 12th, 2018 in Career Development

The following article is reprinted with permission of its author, Vincent Ivan Phipps, M.A., CSP. We want to thank Mr. Phipps for being a keynote speaker at our 2018 Global TapRooT® Summit.  You can purchase his new book, Lead Out Loud, and learn how to unlock your personal excellence by clicking here. Learn more at

Your best marketing plan is your ability to effectively speak. If you are comfortable talking or if you have to muster the courage to speak in front of strangers, adapt you messages to the four types of audiences that are feature in the book, Lead Out Loud! – Keys to Unlock Professional Excellence!.

This type of audience wants short and direct information. Avoid giving too many details and make sure to succinctly cover your main points early and often.

This type of audience needs step by step information. Allocate time for questions and be sure to provide reassurance. Avoid selling too soon before establishing trust.

This type of audience loves humor, engagement and good stories. Hit the high points and name drop. Avoid going into processes and focus on the people

This type of audiences needs data. Be sure to give reference material and cite you sources. Do your research before sharing content to ensure accuracy. Avoid using ambiguous terms and speak with validity.

Adapt to your audience and see your presentation results amplify!

– Vincent Ivan Phipps, M.A., CSP
Certified Speaking Professional, Author and Owner of Communication VIP Training and Coaching

Monday Accidents & Lessons Learned: When a disruption potentially saves lives

Posted: March 12th, 2018 in Accidents

Early news of an incident often does not convey the complexity behind the incident. Granted, many facts are not initially available. On Tuesday, January 24, 2017, a Network Rail freight train derailed in south-east London between Lewisham and Hither Green just before 6:00 am, with the rear two wagons of the one-kilometer-long train off the tracks. Soon after, the Southeastern network sent a tweet to report the accident, alerting passengers that, “All services through the area will be disrupted, with some services suspended.” Then came the advice, “Disruption is expected to last all day. Please make sure you check before travelling.” While southeastern passengers were venting their frustrations on Twitter, a team of engineers was at the site by 6:15 am, according to Network Rail. At the scene, the engineers observed that no passengers were aboard and that no one was injured. They also noted a damaged track and the spillage of a payload of sand.

The newly laid track at Courthill Loop South Junction was constructed of separate panels of switch and crossing track, with most of the panels arriving to the site preassembled. Bearer ties, or mechanical connectors, joined the rail supports. The February 2018 report from the Rail Accident Investigation Branch (RAIB), including five recommendations, noted that follow-up engineering work took place the weekend after the new track was laid, and the derailment occurred the next day. Further inspection found the incident to be caused by a significant track twist and other contributing factors. Repair disrupted commuters for days as round-the-clock engineers accomplished a complete rebuild of a 50-meter railway stretch and employed cranes to lift the overturned wagons. Now factor in time, business, resources saved—in addition to lives that are often spared—when TapRooT® advanced root cause analysis is used to proactively reach solutions.

Equifactor and FMEA

Posted: March 12th, 2018 in Equipment/Equifactor®

equifactor, repair, FMEA









For those of you that have met me, you know that I am a huge fan of proactive improvement processes. Why wait until something bad happens to fix your issues? Wouldn’t it be nice if we could fix problems before we have an incident that actually hurts someone, or damages our equipment?  I’ve spoken numerous times about using TapRooT® proactively for HSEQ problems, but I wanted to give you a tool to help you with your proactive equipment troubleshooting.

Design and process engineers are usually familiar with Failure Modes and Effects Analysis, or FMEA.  This is a generic tool that can be used to look at a piece of equipment or a process, identify what can go wrong, and determine more stringent controls should be put in place to prevent that failure.  There are actually quite a few ways to do this, but most FMEA’s are all based on a fairly standard format.  For this discussion, I’m going to focus on equipment failures.  Generally, the system walks you through several distinct steps:

  1. Identify the piece of equipment you wish to analyze.
  2. Look at all realistic potential failure modes that can occur with that equipment.
  3. Assign a Severity, Occurrence, and Detectability score to each failure
  4. Multiply these scores together to calculate a Risk Priority Number (RPN).
  5. Determine the controls that are currently in place to prevent this issue.
  6. Decide if additional controls are required, based on the RPN.

Now, looking at these steps, it occurs to me that many of these steps are somewhat subjective.  For example on a scale of 1-10, what is the Severity of the failure?  Most companies have put a matrix in place to help quantify these numbers and make it easier to come up with consistent results.  This guidance is really important if you want to have any kind of meaningful, systematic way of determining that RPN.  While not perfect, these matrices do a pretty good job of keeping everyone focused and getting consistent answers.

However, the one step that is still VERY subjective is step #2.  Somehow, you need to come up with a list of all the potential failure modes that your piece of equipment can experience.  This is the very basis of the entire analysis, and it is probably the most difficult.  Imagine telling your maintenance manager or design engineer, “Tell me all the ways this compressor can fail.”  While I’m sure your team is pretty sharp, this is a daunting task.  Ideally, they will need to list every possible failure mode to ensure we don’t miss anything.  Imagine how many “unknown unknowns” are floating around in our FMEA’s!

Wouldn’t it be nice if there were some compendium of possible failures that we could use to initially populate our FMEA list?  This is where I would recommend pulling up your Equifactor® tables.  Take a look at (for example) the Centrifugal Compressor troubleshooting tables.  Just in this category alone, we have nearly 50 possible failure modes, spread across 7 symptoms.  Imagine if you could start your FMEA with all of these items.  You’d be well on your way to conducting a detailed FMEA on your centrifugal compressors, with the ability to add a few more failure modes that may be unique to your situation.

We normally think about Equifactor® as a reactive troubleshooting tool.  While it excels in that mode, try using the Equifactor® tables more proactively.  Use those tables as the baseline for your FMEA, and limit the number of unknown issues that may be lurking in your equipment.


Career Opportunities for Candidates with TapRooT® Skills

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

Let your expertise speak for itself. Professional training and skill sets in investigation, problem-solving, and root cause analysis will telegraph competency to the potential employer across the desk from you. If you have TapRooT® training and skills, step up into a new career through one of these global opportunities.

Chemical Laboratories and Corporate Office

QHSSE Advisor

Manager, Safety & Health

EHS Manager II

Service Delivery Coordinator

HSE Site Supervisor

Being TapRooT® trained in troubleshooting and identifying root causes of issues and incidents is the proven path to develop your skill sets and training. Pursue your goals through TapRooT® courses to advance your professional development.

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

Bogota, Colombia, March 21, 2018, 3-Day TapRooT® Equifactor®

Brisbane, Australia, April 16, 2018, 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Las Vegas, NV, April 23, 2018, 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

TapRooT® Around the World

Posted: March 9th, 2018 in Courses, TapRooT

TapRooT® instructor, Heidi Reed, sent us these photos from a course that she and Barry Baumgardner are teaching at Energy XXI in Grand Isle, LA. Looks like a great group!


Want to learn about your onsite course options?

Contact us!

2018 TapRooT® Global Summit Twitter Highlights

Posted: March 9th, 2018 in Pictures, Summit

First, I would like to start off by thanking everyone who attended the Summit this year. It was a great success, and we here at System Improvements received lots of positive feedback from everybody. Without our amazing clients, instructors, and employees we wouldn’t be here today so thank you! Because of you, we get to be in the business of saving peoples lives.

Okay, I am finished with the mushy stuff… Let us get on with the fun photos!

The Twitter Contest was a huge success. We received tons of photos, quotes, and videos. So many in fact there is no way I could include every tweet. If I did the post would be 5,000 pages long!

Below are just a few of my favorite tweets I saw through out the week. If you would like me to generate more posts with more of my favorite tweets please leave it in a comment below, or email me at


Friday joke

Posted: March 9th, 2018 in Jokes

Caption Contest!

Posted: March 8th, 2018 in Contest, Pictures

Now that the Summit is over we can begin a new caption contest! I’m not sure that when your boss says, “Get the job done safely…” that this is exactly what he had in mind. Read and follow the instructions below so you can qualify to win.

How would you caption the above photo? Put on your creative hat and read the contest instructions below. Enter as many times as you want, and if you’ve won our contest before, you are still eligible to enter this one!

Contest Instructions:
1. Create your caption to the photo above in five words or less. All captions with more than five words will be disqualified.
2. Type your caption in the comments section of this post by April 2, 2018.
3. If you haven’t already, subscribe to the Tuesday TapRooT® Friends & Experts e-newsletter. You must be a subscriber to win!

Have fun!

Keeping Your Equipment Reliability Team Sharp

Posted: March 7th, 2018 in Career Development, Equipment/Equifactor®, Summit

study, read, reliability, troubleshoot








We have just completed our annual Global TapRooT® Summit, and we all walked away with some terrific ideas to bring back to our companies. Many people think the Summit is only for our customers to improve their processes, but I ALWAYS come away with new ideas for myself.

Heinz Bloch was one of our speakers this year.  He had 2 excellent sessions on how equipment reliability is tied directly to your company’s bottom line.  As always, he had some great insights into how a company can integrate reliability techniques into their business model for real, measurable savings.

One of his observations is that, as technology progresses, it is imperative that your reliability and maintenance team  keep up-to-date on the current best practices and technologies.  It is too easy to assume your excellent reliability and maintenance engineers will just magically remain top-notch.  His suggestion (almost a demand!) was to ensure we give our team the time and motivation to actually READ about their craft.  Your team should be allocating some amount of time EVERY DAY to reading professional journals and articles to see what is happening outside their own company boundaries.

  • Are you using the very best lubricant?
  • What new bearing materials are available for your applications?
  • How much can we save by investing in slightly more expensive, but much more efficient technology?
  • What are our competitors using for condition-based maintenance?

As managers, we should be giving our team both the time and the incentive to read these journals and articles.  Trust me, your competition is doing this; don’t be left behind!

What does bad root cause analysis cost?

Posted: March 7th, 2018 in Accidents, Performance Improvement, Pictures, Root Cause Analysis Tips, Training


Have you ever thought about this question?

An obvious answer is $$$BILLIONS.

Let’s look at one example.

The BP Texas City refinery explosion was extensively investigated and the root cause analysis of BP was found to be wanting. But BP didn’t learn. They didn’t implement advanced root cause analysis and apply it across all their business units. They didn’t learn from smaller incidents in the offshore exploration organization. They didn’t prevent the BP Deepwater Horizon accident. What did the Deepwater Horizon accident cost BP? The last estimate I saw was $22 billion. The costs have probably grown since then.

I would argue that ALL major accidents are at least partially caused by bad root cause analysis and not learning from past experience.

EVERY industrial fatality could be prevented if we learned from smaller precursor incidents.

EVERY hospital sentinel event could be prevented (and that’s estimated at 200,000 fatalities per year in the US alone) if hospitals applied advanced root cause analysis and learned from patient safety incidents.

Why don’t companies and managers do better root cause analysis and develop effective fixes? A false sense of saving time and effort. They don’t want to invest in improvement until something really bad happens. They kid themselves that really bad things won’t happen because they haven’t happened yet. They can’t see that investing in the best root cause analysis training is something that leads to excellent performance and saving money.

Yet that is what we’ve proven time and again when clients have adopted advanced root cause analysis and paid attention to their performance improvement efforts.

The cost of the best root cause analysis training and performance improvement efforts are a drop in the bucket compared to any major accident. They are even cheap compared to repeat minor and medium risk incidents.

I’m not promising something for nothing. Excellent performance isn’t free. It takes work to learn from incidents, implement effective fixes, and stop major accidents. Then, when you stop having major accidents, you can be lulled into a false sense of security that causes you to cut back your efforts to achieve excellence.

If you want to learn advanced root cause analysis with a guaranteed training, attend of our upcoming public TapRooT® Root Cause Analysis Training courses.

Here is the course guarantee:

Attend the course. Go back to work and use what you have learned to analyze accidents,
incidents, near-misses, equipment failures, operating issues, or quality problems.
If you don’t find root causes that you previously would have overlooked
and if you and your management don’t agree that the corrective actions that you
recommend are much more effective, just return your course materials/software
and we will refund the entire course fee.

Don’t be “penny wise and pound foolish.” Learn about advanced root cause analysis and apply it to save lives, prevent environmental damage, improve equipment reliability, and achieve operating excellence.

TapRooT® on Worldwide Business with Kathy Ireland®

Posted: March 6th, 2018 in Uncategorized

Mark’s segment on Worldwide Business with Kathy Ireland® will be airing Sunday, March 11, 2018, on Bloomberg International at 7:00 am, GMT.

Mark your calendars, set an alarm, and set your DVR to record. You won’t want to miss out!

Below, tell us your success story about using TapRooT®.

Protection Against Hydrogen Sulfide

Posted: March 6th, 2018 in Accidents, Investigations

On January 16, 2017, a private construction company sent four utility works to handle complaints about sewage backup in Key Largo, Florida. Three of the four works descended into the the 15-foot-deep drainage hole, and within seconds all voice communication was lost amongst the construction workers.

The Key Largo Fire Department was the first to respond to the scene. Leonardo Moreno, a volunteer firefighter, tried to enter the hole with his air tank but failed. So, he descended without his air tank and lost consciousness within seconds of entering the drainage hole. Eventually, another firefighter was able to enter the hole with an air tank and pull Moreno out. Unfortunately, the other three construction workers weren’t so lucky. All of them died from hydrogen sulfide poisoning, and Moreno was in critical condition.

Unfortunate events like this are completely avoidable. Comment below how this could have been avoided/prevented by using TapRooT® proactively.

To learn more about this tragic incident click here.

Is Having the Highest Number of Serious Incidents Good or Bad?

Posted: March 6th, 2018 in Accidents, Current Events, Medical/Healthcare, Pictures


I read an interesting article about two hospitals in the UK with the highest number of serious incidents.

On the good side, you want people to report serious incidents. Healthcare has a long history of under-reporting serious incidents (sentinel events).

On the good side, administrators say they do a root cause analysis on these incidents.

On the bad side, the hospitals continue to have these incidents. Shouldn’t the root cause analysis FIX the problems and the number of serious incidents be constantly decreasing and becoming less severe?

Maybe they should be applying advanced root cause analysis?

Highlights from the 2018 Global TapRooT® Summit

Posted: March 5th, 2018 in Performance Improvement, Pictures, Summit, Video

IMG 7328

Coming up with a highlight reel from the 2018 Global TapRooT® Summit is almost impossible. I always think that the Summit just can’t get any better and then we outdo ourselves planning the next one. Here are some highlights followed by the top six items attendees shared that they needed to do better at their facilities.

First, a video to share the experience…

By the way, the next Global TapRooT® Summit is scheduled for March 11-15, 2019, in Houston (Montgomery, TX) at the La Torretta Lake Resort & Spa (picture below).

Screen Shot 2018 03 05 at 11 54 44 AM

Now for my impressions of the highlights …

First, the Keynote Speakers were outstanding.

We started with Dr. Carol Gunn who gave an inspiring talk about medical errors and how to encourage error reporting and effective investigations. Carol is a TapRooT® User and medical doctor … she knows what she is talking about.

Next, we had an UNBELIEVABLE talk by Boaz Rauchwerger who told us all to take a positive approach to improvement.

IMG 7342

The final keynote on Wednesday was Inky Johnson. How can I explain how he inspired us? There was a long line of people who just came up to thank Inky and get their picture taken with him. If you don’t know Inky’s story. watch it below for motivation to accomplish more in life.


After Inky’s keynote, Carl Dixon entertained us at the Summit Reception. Here I am singing Proud Mary with him…


On Thursday, I was the opening keynote and concluded with a TapRooT® Implementation Gap Analysis. People shared where they needed to improve their TapRooT® implementation. What were the top 6 items they needed to do better?

  1. Use advanced root cause analysis (TapRooT®) for both reactive and proactive investigations.
  2. Use an investigation rewards program more effectively.
  3. Guide their improvement programs through management’s use of performance measures and advanced trending techniques.
  4. Proactive improvement that drives improvement success (tie with 5).
  5. Develop a leadership succession plan.
  6. Communicate improvement accomplishments successfully.

These items will help us plan sessions for next year’s Summit.

Screen Shot 2018 03 05 at 1 39 03 PM

Vincent Phipps closed out the day with his discussion of the four personality types and how to use them to communicate more effectively.

On Friday we started with the session that helped attendees develop plans to fill their program gaps (started with the gap analysis performed on Thursday).

IMG 7338


Then, I (Mark Paradies) interviewed Mike Williams about his experiences when the Deepwater Horizon experienced a blowout, explosion(s), and fire. Wow! What an experience. People were sitting on the edge of their seats as Mike answered my questions and all the questions from the Summit participants. We actually ran over the finish time by 15 minutes as people asked interesting questions. The lessons learned from this one session about emergency response, investigations, and safety were … UNBELIEVABLE! I learned several things about the accident that I didn’t know from the various reports (CSB, Presidential Commission, BP, or Coast Guard) that added to my understanding of the Causal Factors and root causes. There was also an important lesson for investigators about empathy and PTSD after a major accident.

And that’s just a summary of the Keynote Speakers impact. There were also some great Best Practice Sharing sessions and speakers. My favorite was the TapRooT® Users Share Best Practices Session (soon, you will be seeing videos from this session to share some of the best practices).

Here are what some TapRooT® Users had to say about their 2018 Global TapRooT® Summit experience…


What a Summit! Hope to see you in Houston in 2019!

Career Opportunities for Candidates with TapRooT® Skills

Posted: March 5th, 2018 in Career Development, Job Postings

With professional training and the acquisition of skill sets in investigation, problem solving, and root cause analysis, your expertise will shine through to employers. If you have TapRooT® training and skills, consider one of these global opportunities.

Regional HSE Advisor

Manager – EHS/Quality

Industrial Hygiene/Occupational Health Facilitator (Field)

Energy Plants Services Manager

Associate-Senior Engineer Nuclear (Electrical)

Being TapRooT® trained in troubleshooting and identifying root causes of issues and incidents is the proven path to develop your skill sets and training. Pursue your goals through TapRooT® courses to advance your professional development.

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

Bogota, Colombia, March 21, 2018, 3-Day TapRooT® Equifactor®

Brisbane, Australia, April 16, 2018, 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Las Vegas, NV, April 23, 2018, 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Monday Accidents & Lessons Learned: When a critical team meets the unexpected

Posted: March 5th, 2018 in Accidents

Teamwork can break down or go awry in difficult circumstances. During normal operations, team members adhere to policy for their roles, but a single incident can challenge or splinter even the most prepared team. Flight passengers can create a variety of circumstances that require quick and exceptional thinking and action; many of these circumstances are not delineated or addressed in the Quick Reference Handbook (QRH) or by company policy.

This happened to an air carrier crew in an aircraft on the runway awaiting takeoff. The crew was suddenly caught up in a passenger’s panic-stricken, emotionally charged request to deplane. CALLBACK, from NASA’s Aviation Safety Reporting System, allows us six crew debriefing perspectives from this incident. From the First Officer’s report to both Flight Attendants’ summaries, we can view and, using TapRooT@ Techniques, interact with the complications that accompanied each vantage point.

Friday joke

Posted: March 2nd, 2018 in Jokes

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