Root Cause Analysis Software & Training Experts
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TapRooT® is a systematic process, software, and training for finding the real root causes of problems. It is used by leading companies around the world to investigate and fix the root causes of major accidents, everyday incidents, minor near-misses, quality issues, human errors, maintenance problems, medical mistakes, productivity issues, manufacturing mistakes, environmental releases … in other words, all types of mission-critical problems.
System Design and Testing
- Systematic process based on in-depth human factors and equipment reliability research.
- Designed to keep investigators out of common investigator traps including the blame game and jumping to conclusions.
- Tested by major governmental and industrial clients around the world and continuously improved to produce reliable, repeatable, explainable results.
System Features and Continuous Improvement
- An expert system that leads investigators beyond their current knowledge and makes them feel like they have a human factors expert sitting beside them when analyzing human errors.
- Not just a root cause analysis system, but a complete investigation process that helps investigators collect the information they need to find root causes.
- Patented TapRooT® Software (either web based or individual user) to make the system more efficient and to create a database of investigation results.
- Excellent training that can be as extensive or as simple as required for the needs of those being trained.
- Copyrighted Root Cause Tree®, Dictionary, and Corrective Action Helper® developed by our staff of experts and continuously improved.
- An advisory board of over 60 industry and governmental leaders that provides ideas for improving TapRooT®.
- Equifactor® troubleshooting tables (licensed from Heinz Bloch) for troubleshooting equipment failures.
- Excellent documentation in a readable, best-selling book (over 60,000 copies sold) – TapRooT®: Changing the Way the World Solves Problems
- A worldwide network of exceptional instructors and investigators with extensive real world experience they bring to courses, and who are also available to assist with difficult investigations at your site.
- Worldwide user network and a user discussion site (on LinkedIn) for benchmarking and networking (over 10,000 people per year are trained in TapRooT® around the world).
- Three free newsletters (one weekly, one bi-monthly, and one quarterly) to promote continued learning of advanced root cause analysis, equipment troubleshooting, and performance improvement ideas.
- An annual, global Summit to promote networking, benchmarking, and learning of advanced best practices and the most recent performance improvement technology.
The TapRooT® System is based on advanced, proven human performance and equipment reliability technology. This knowledge was built into the TapRooT® System so that every person investigating problems can take advantage of the knowledge of experts without having to spend years studying human and equipment performance.
TapRooT® History (The rest of the story)
The TapRooT® System, Training, and Software have a long history of R&D and improvement that continues today. Over 20 years ago, we started with 6 years of research into human performance and the best incident investigation and root cause analysis systems. Then we put our knowledge to use to build a systematic investigation process with a coherent investigation philosophy. We then used and refined the system in the field. We’ve performed formal user testing and informal focus group appraisals. In 1991, we wrote the first TapRooT® Manual that put all of this experience together into the best incident investigation system – TapRooT®!
But we didn’t stop there. We continued improving the system with feedback from thousands of users from our ever-growing international user base. We improved the TapRooT® Book and Courses. And we developed the patented TapRooT® Software to improve investigation productivity. Our groundbreaking research and development and our continuing improvement efforts are the reasons that TapRooT® is used by so many industry leaders worldwide.
But don’t take our word for it. Instead, see what TapRooT® users have to say about their successes. Read the Success Stories that explain how users stopped injuries, saved lives, improved investigation effectiveness and productivity, stopped finger pointing and blame, improved equipment reliability, and fixed operating problems that saved big bucks.
Analyzing human performance was the original focus of TapRooT®. It still is one of its biggest strengths. Mark Paradies, co-developer of the TapRooT® System, became familiar with advanced human factors technology during his studies at the University of Illinois. Mark had been in the Nuclear Navy and was familiar with errors that operators and mechanics make (even when they are well-trained & have good procedures). He learned theories behind human error and advanced concepts to correct human factors problems.
Advanced human factors concepts aren’t very accessible to plant personnel, engineers, and managers (who generally aren’t trained in human factors). So Mark built these concepts into TapRooT®. This required careful design to include advanced human performance technology without the jargon used by experts. Mark Paradies and co-developer Linda Unger crafted a system that includes advanced human performance concepts without being too complex. What advanced human factors concepts are in TapRooT®?
The list is too long to read here, but it includes:
- The SOR Model of Human Performance
- Rasmussen’s Skill-Rule-Knowledge Model
- Knowledge of Advanced Job Performance Aids
- The Systematic Approach to Training (SAT)
- Application of Cockpit Resource Management
- Ergonomics (anthropometrics)
- Communication reliability practices
- An advanced behavior change model
- Charles Hopkins’ human factors theories
- Chris Wickens’ concepts on mental models
- James Reason’s Swiss Cheese Model of error
- Paradies/Unger’s human performance troubleshooting model
You don’t have to learn these concepts, have a PhD in Psychology, or hire a human factors expert to take advantage of this technology. Just answer the questions and follow the guidance that TapRooT® provides to find the root causes of human error.
Besides advanced human performance technology, TapRooT® also has advanced equipment troubleshooting technology built into the system.
In 1997, Mark Paradies started working with equipment reliability expert Heinz Bloch to develop a system to improve the analysis of equipment failure. Mark, Andy Marquardt, and Ken Reed have worked with Heinz to develop a system, course, and software for equipment troubleshooting and root cause analysis that combines Heinz Bloch’s techniques with the power of SnapCharT®s, Change Analysis, and the TapRooT® Root Cause Tree®. We called this advanced equipment troubleshooting technology Equifactor®. In 2000, it was fully integrated into the TapRooT® Book and Software to make TapRooT® the complete root cause analysis system for all types of problems.
More Continuous Improvement
Of course, TapRooT®‘s development didn’t stop there. People at System Improvements are constantly looking for ways to improve the TapRooT® System, Documentation, Training, and Software. In 2008, they published a completely new TapRooT® Book. In 2010 Ed Skompski and Dan Verlinde led a software development team who released the initial version 5 of the TapRooT® Software, a complete software rewrite from the ground up. Keep an eye on the Root Cause Analysis Blog for news about all the latest improvements to TapRooT®.
How Does the TapRooT® System Work?
The TapRooT® System is a 7-Step Investigation Process with built in tools that help an investigator like you:
- Collect information.
- Understand what happened.
- Identify the problems that caused the incident.
- Analyze each problem’s root causes.
- Look beyond root causes for systemic, cultural, and organizational factors.
- Develop fixes to improve performance and stop repeat incidents.
- Present what’s been learned to management so they can understand and approve the fixes.
The first steps of the 7-Step Investigation Process are to plan the investigation, collect information, and understand what happened. The investigator draws a SnapCharT® to understand what happened and to organize the information about what happened. Below is a simple SnapCharT® that a team has started to build about a simple accident – a sprained ankle.
The initial investigation work will uncover more information about the incident’s events until the investigator or team can completely understand what happened. Then they can identify all the Causal Factors (problems) that came together to cause the accident/incident. These Causal Factors can be displayed on a more advanced SnapCharT® (as in the SnapCharT® below).
Once the investigators have identified all the Causal Factors, they can analyze each of the problems to determine the problems’ root causes. A Causal Factor can have more than one “root cause.” TapRooT® has a special tool, the Root Cause Tree® and Dictionary, to help investigators find root causes of the Causal Factors.
The Root Cause Tree® is a copyrighted, trademarked, and patented (in the software) tool for analysis of root causes. It was initially developed by Mark Paradies, David Busch, and Linda Unger to help people perform better root cause analysis of human performance and equipment reliability problems. It uses the latest human performance and equipment reliability technology to help investigators in the field find root causes. It has extensive development history including testing in many industries and feedback from users around the world.
The Root Cause Tree® has seven Basic Cause Categories. One of the Basic Cause Categories – Procedures (graphic below) – shows the root cause level that investigators strive to reach. The graphic also shows the human factors research that is built into the Procedures section.
Also built into the Root Cause Tree® is a 15-question Human Performance Troubleshooting Guide that helps investigators dig into human errors to find their root causes by considering a wide range of factors. Three of the questions are shown below to demonstrate how the Human Performance Troubleshooting Guide gets investigators to consider different areas that could contribute to human error.
To ensure consistent use of the Root Cause Tree®, the Root Cause Tree® Dictionary was written to clearly define each of the categories/root causes and guide investigators to the root causes of human performance problems.
Once all the root causes have been identified for a problem, the TapRooT® System then helps the investigator look for Generic Causes (big picture problems related to culture, systemic, and organizational problems).
Once the root and generic causes have been identified, the investigator can use the Corrective Action Helper® and SMARTER tools to develop effective corrective actions to prevent future problems.
Finally, TapRooT® tools can be used to present what was found to management and others.
That’s how the TapRooT® System helps solve problems.
The TapRooT® Training teaches investigators how to effectively use each tool in a systematic investigation process. Using TapRooT® will become second nature – as it has for the 10,000+ people who are trained each year to use TapRooT®.
Using TapRooT® can be simplified for quick, easy investigations. Thus, TapRooT® is flexible; it can be used for analyzing simple incidents or minor equipment failures or significant accidents that cost lives and millions of dollars. See the range of applications of TapRooT® by reviewing the success stories here.
The whole process is documented in the TapRooT® Book – a complete reference provided with the TapRooT® Training.
For a more detailed look at how TapRooT® works, see the environmental incident example here.
In 1990, we started developing the TapRooT® Software. In 2002, the TapRooT® Software received a US patent. Software updates are released several times each year.
TapRooT® Software comes in two forms: Enterprise and Single-User.
The Single-User TapRooT® Software can be loaded on a PC to computerize the TapRooT® Tools. Individual investigators keep a database of their investigations. The software includes all the TapRooT® techniques. These techniques are organized in an interface built around the TapRooT® 7-Step Investigation Process so that everything is easy for the user to access.
The software also includes an incident database to store the information, a corrective action database to save and track the corrective actions, and databases to store other information (pictures, documents, procedures, …).
The Enterprise Software takes the same tools and makes them available over the company intranet. This allows easier installation, updates, administration, and backup of the software. It also allows reporting of incidents from any connected PC, collaboration of multiple investigators at separate locations over the net, and online management reviews.
TapRooT® is the most effective, tested, documented root cause system used by industry leaders around the world. One of the most impressive parts of the TapRooT® System is the training that helps people see problems from a whole new perspective. That’s why TapRooT® Training comes with the following Money Back Guarantee:
Attend a TapRooT® Course. Go back to work and use what you have learned to analyze accidents, incidents, near-misses, 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 and we will refund the entire course fee. No questions asked – no hard feelings – it’s that simple.
Here are the three standard TapRooT® Courses to improve investigations and root cause analysis …
The 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course teaches the essential techniques to analyze an incident. CLICK HERE for more details.
The 3-Day TapRooT®/Equifactor® Equipment Troubleshooting and Root Cause Analysis Course includes the material from the 2-Day TapRooT® Course and adds a day of equipment troubleshooting practice using the computerized Equifactor® Equipment Troubleshooting Tables. CLICK HERE for more details.
The 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course is for those who:
- Are responsible for the performance improvement at their site or company.
- Investigate significant accidents.
- Coach other TapRooT® Users.
- Want to learn all the optional TapRooT® techniques.
- Want to learn advanced interviewing techniques.
- Are interested in the causes of human error.
- Are the TapRooT® expert for their company.
- Plan to become a Certified TapRooT® Instructor.
For complete 5-Day TapRooT® Course info, CLICK HERE.
If you have questions about the TapRooT® System, Training, or Software, please feel free to contact us by CLICKING HERE.