Changing the Way the World Solves Problems
Using the Essential TapRooT® Techniques
to Investigate Low-to-Medium Risk Incidents
Learn to do investigations for low-to-medium risk incidents as fast and easy as possible with credible results and effective corrective actions. Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents makes TapRooT® simple to understand in just 50 pages.
Chapter 1: When is a Basic Investigation Good Enough?
Chapter 2: How to Investigate a Fairly Simple Problem Using the Basic Tools of the TapRooT® Root Cause Analysis System Improvements
- Find Out What Happened & Draw a SnapCharT®
- Decision: Stop or More to Learn?
- Find Causal Factors Using Safeguard Analysis
- Find Root Causes Using the Root Cause Tree® Diagram
- Develop Fixes Using the Corrective Action Helper Module
- Optional Step: Find and Fix Generic Causes
- What is Left Out of a Basic Investigation to Make it Easy?
Chapter 3: Comparing the Results of a 5-Why Investigation to a Basic TapRooT® Investigation
Appendix A: Quick Reference: How to Perform a Basic TapRooT® Investigation
About the Authors
Mark Paradies and Linda Unger are co-developers of the TapRooT® system. Mark has a BS in Electrical Engineering and an MS in Nuclear Engineering (with an emphasis on human factors), both from the University of Illinois. Linda has a BS in Electrical Engineering from the University of Tennessee and human factors training from the University of Michigan.
TapRooT® Book – Changing the Way the World Solves Problems (OUT OF PRINT)
You can join the improvement revolution sweeping the world and fix the root causes of problems. How? With the secrets of root cause analysis and performance improvement explained in this book. Learn how people:
- Turn a money-losing, unreliable chemical plant into a high quality, money making, award winning operation.
- Transform a coal mine’s average safety record into an award winning, industry leading program.
- Save over $1,000,000 per year in workers’ compensation costs at an R&D, order fulfillment, and warehouse facility by stopping ergonomic injuries.
- Change the work environment from one where people didn’t report or fix problems into one where people willingly participated in performance improvement and problem solving.
- Improve a good safety record at a microchip manufacturing plant into an amazingly good record.
- Cut time & effort from the investigation of an operating problem so that the problem’s root causes were identified without slowing down the plant recovery process.
- Improve union-management relations by promoting cooperative problem solving.
These are a few of the successes that TapRooT® Users have achieved by finding and fixing the root causes of problems. These success stories are chronicled our Success Stories page. Review the stories and you will want this book!
This book is the culmination over 20 years of research and development. Five prior books and manuals have documented the TapRooT® approach to finding the root causes of accidents, incidents, quality problems, equipment failures and sentinel events. This 500-page book is jam-packed with useful techniques, tools, strategies, information, and processes, including tools for:
- Accident/incident/near-miss investigations
- Proactive performance improvement
- Performance measurement and trending
- Improvement program development
- Improving existing improvement programs (Lean, Six Sigma, Process Safety Management, …)
The TapRooT® Book starts by describing the theory behind accident causation and root cause analysis. This description includes the basis for the TapRooT® approach to root cause analysis and the science behind the Root Cause Tree®.
Next, Chapter 2 suggests strategies for leaders to apply root cause analysis in their performance improvement efforts. This helps management see how root cause analysis fits into their business processes.
Chapter 3 presents almost 100 pages describing the TapRooT® 7-Step Reactive Investigation Process used to investigate an accident, incident, quality issue, equipment failure, or sentinel event. This information includes:
- How to plan an investigation (and what tools to use)
- Determining sequence of events that led to the problem
- Information collection guidance
- A 14-Step Cognitive Interviewing Process
- How to define Causal Factors (a new, systematic method)
- How to analyze each Causal Factor using the Root Cause Tree®
- Going from Specific Root Causes to determine Generic Causes
- How to develop corrective actions (including the use of the SMARTER Matrix, Safeguards Analysis, and the Corrective Action Helper® Book)
- A corrective action implementation process
Chapter 4 explains how the use of the same tools used to reactively investigate accidents can be used to proactively find problems and fix them before an accident happens. This includes using TapRooT® in audits, assessments, and observations, as well as bigger proactive improvement programs. Chapter 4 explains how TapRooT® can be used in specific proactive improvement programs including Lean, Six Sigma, and Behavior Based Safety.
Chapter 5 includes extensive, advanced information about performance measurement and trending. From simple techniques to advanced statistical methods that help investigators trend infrequently occurring accident data.
Are you interested in starting or improving a performance improvement program? The book includes a chapter titled, “Leadership Vision and Strategy To Build a Performance Improvement Program” that provides exceptional guidance. It also includes a new Appendix titled, “A Guide to Improving the Use of TapRooT®” that’s specifically written for those looking to improve the use of TapRooT® at their facilities.
The book also includes detailed “user’s manual” chapters for each of the major TapRooT® Tools, including:
- Root Cause Tree®
- Equifactor® Equipment Troubleshooting
- Safeguards Analysis
- Change Analysis
- Critical Human Action Profile (CHAP)
These manuals provide exceptional reference material for people even if they have previously attended TapRooT® Training.
You won’t be left saying: “Where’s the Beef?” when you read this book. Instead, you will be left wondering: “How did I ever solve problems without this helpful, systematic process?”
Want to know more first? Download a copy of the Table of Contents from the Root Cause Analysis Blog!