Category: Presentations

Prepare your Investigation Results for Management

October 24th, 2016 by

presentation-36911_1280After you’ve concluded a TapRooT® investigation, preparing your investigation results for management doesn’t have to be a chore.  If you have TapRooT® software, you can avoid creating a Powerpoint completely!  Learn how here.

If you prefer to add content to a PowerPoint, the TapRooT® tools that helped you complete your investigation will also help you create a presentation that gets their attention.  Here is a simple guideline of what content to add from your TapRooT® investigation:

  • After your introduction slide, clearly and simply state the incident and the determined results in two to three sentences.
  • On the next slide, present a small section of your SnapCharT® that explains the incident.  For most incidents, it will include four to six Events (Squares) leading up to the incident, as well as the the incident (Circle), and one or two Events that occurred after the Incident.  Only present the first line of the SnapCharT® (the Events) on this slide.
  • Then add slides with visuals.  You have already documented evidence through photographs and videos and maybe even sketched arrangement/placement in Steps 1 and 2 of the TapRooT® 7-Step Major Investigation Process.  You can use these items as Powerpoint visuals.  But how many should you use?  Use the visuals that most clearly support your results – just a few will suffice depending on the complexity of the incident.
  • Then present slides that contain each section of your SnapCharT® that includes a Causal Factor – one Causal Factor section per slide.  Include Events and Conditions this time.  Write the Root Cause next to each Causal Factor determined.  Do not present the Root Cause Tree.  Why?  Because then you are providing a pick-list for management to analyze and they have not put in the hours analyzing the SnapCharT® and finding supporting evidence.
  • Finally, create a slide that presents your Corrective Actions in an easy-to-read column or table format.  For example, list the Root Cause in Column 1, the Corrective Action in Column 2 and who will implement the Corrective Action (and the deadline for implementation) in Column 3.

To practice preparing and presenting results to management, sign up for our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training.  You can even bring a real incident from your facility!

Tulsa Public 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

November 4th, 2014 by

Final case studies being presented in our Tulsa, Oklahoma course.

Image 4 Image 5 Image 6 Image 7

For more information on our public courses click here or to book your own onsite course click here.

Lessons *Not* Learned from Deepwater Horizon & Texas City (and How to Improve Investigations)

March 3rd, 2014 by

Mark Paradies, President of System Improvements, Inc./TapRooT®, presents a view of lessons *not* learned according previous reports related to Deepwater Horizon & Texas City. In this 2013 Global TapRooT® Summit presentation he critiques the failure to learn and prevent accident recurrence, and offers suggestions to improve investigations.

View four-part video of this presentation:

Part One

Part Two

Part Three

Part Four

If you need a kindergartner to explain your control chart for you….

December 20th, 2013 by

Watch two children explain their morning routine using a process flow chart and a control chart.

If you do not have a knowledgeable kindergartner hanging around to help you, I would recommend attending the following this April during our TapRooT® Summit Week:

Advanced Trending Techniques

TapRooT® Quality/Six Sigma/Lean Advanced Root Cause Analysis Training

Process Quality and Corrective Action Programs

Mark Paradies Talks About Rickover, Process Safety, and Fatality Prevention

May 15th, 2013 by


There are too many major accidents due to failures in process safety. These accidents go beyond the regulations written by OSHA and EPA (and the regulators in other countries). They go beyond the chemical industry and include the nuclear industry, oil exploration and production, fertilizer storage and distribution, grain elevators (and other dust explosion examples), aviation, shipping, utilities, and even hospitals.

How can these accidents be prevented? First one has to understand process safety and fatality prevention. Unfortunately, many senior managers don’t understand it. And that’s why Mark Paradies started giving talks about this topic at the TapRooT® Summit. Unfortunately, even though the Summits are well attended, thousands need to hear what Mark has to say, but don’t get the chance. That’s why we decided to post links to some of Mark’s Summit talks here.

Of course, attending the sessions at the TapRooT® Summit is much better than looking at slides and watching videos. But the information in these talks needs greater dissemination to help prevent major accidents around the world. Therefore, we’ve selected video clips, slides from mark’s talks, and Admiral Rickover’s testimony before Congress after TMI (written remarks) to provide an overview of some of the concepts that senior managers need to consider to prevent major process safety accidents.

Here are the links:

Mark’s General Session Talk About Fatality Prevention from the 2013 Summit

Marks Talk About SIF Prevention from the 2013 Summit (Part 1)

Mark’s Talk About SIF Prevention from the 2013 Summit (Part 2)

Mark’s Talk About SIF Prevention from the 2013 Summit (Part 3)

Mark’s Talk About Process Safety & Rickover from the 2012 Summit (Part 1)

Mark’s Talk About Process Safety & Rickover from the 2012 Summit (Part 2)

Mark’s Talk About Process Safety & Rickover from the 2012 Summit (Part 3)

Mark’s Slides About Rickover & Process Safety from the 2010 Summit

Rickover’s Testimony to Congress About Reactor Safety (Process Safety)

I know this is a lot of information and the videos are long, but the lives lost each year are a preventable tragedy. Please pass this information on to those that you think many need it.

For those who would like to get Mark to talk to your senior management about management’s role in process safety and how the lessons from Admiral Rickover apply to your facilities, call us at 865-539-2139 or e-mail us by CLICKING HERE.

Admiral Rickover & Process Safety

March 26th, 2013 by

I promised people at the 2013 Global TapRooT® Summit that I would post links to last year’s talk about Admiral Rickover and process safety and a link to his testimony to Congress about nuclear safety and the Nuclear Navy. Here they are…

Nuclear Navy & Process Safety

Rickover’s Testimony to Congress about Nuclear Safety

And here are the slides from the Nuclear Navy and Process Safety talk mentioned above…

Mark Paradies Speaks at 2013 IOSH Conference

February 27th, 2013 by

Mark gave two well received talks at the 2013 IOSH Conference in London.

Because of the many requests for copies of his talks (Deepwater Horizon & Texas City … Three Lessons You May NOT Have Learnt and The Safety Pyramid & Stopping Major Accidents), PDFs of the talks are posted below.



Mark Paradies Speaking at the IOSH Conference

February 12th, 2013 by


Mark Paradies, President of System Improvements and co-creator of the TapRooT® System, will be speaking at the IOSH Conference in Spotlight Theatre 2 on Tuesday, February 26, and Wednesday, February 27.

His topics are:

Tuesday: 13:20 – 13:50 – Spotlight Theatre 2
BP Deepwater Horizon & BP Texas City Accidents: Two Lessons That You May NOT Have Learned

Much has been published about the BP Deepwater Horizon and Texas City Refinery accidents. But there are still some important lessons learned that people may be overlooking. Mark Paradies, root cause analysis expert, will share insights into two lessons learned that have not received much attention yet are important to safety improvement.

Wednesday: 11:20-11:50 – Spotlight Theatre 2

Fixing The Safety Pyramid & Stopping Major Accidents

Several articles have been published criticizing Heinrich’s Safety Pyramid and blaming it’s weaknesses for the gap between the decline in safety statistics and the continuing level rate of serious injuries, including fatalities. Mark Paradies will share insight into the Safety Pyramid and explain why fatality prevention needs a revised model and new approaches to achieve across the board safety performance improvements.

Hope to see you there!

Budapest Conference on EHS

September 29th, 2012 by

Mark Paradies and Linda Unger attended the Budapest Conference on EHS in Emerging Markets.

Mark gave a talk: Solving Root Cause Analysis Problems by Using Advanced Root Cause Analysis. Here’s some pictures of Mark Speaking …




Linda talked to prospective TapRooT® Root Cause Analysis System users and explained how they could learn about and implement TapRooT® at their sites across Europe.



Root Cause Analysis Tip: TapRooT® Summit Session on Process Safety (Part 3)

April 11th, 2012 by

This week is our third and final installment of Mark Paradies’ Summit talk on process safety in the Nuclear Navy.

In this 35-minute clip, you’ll learn how Admiral Rickover’s process safety standards compare to OSHA and CCPS standards, and what that means for your safety program.

Click here for Part 1.

Click here for Part 2.

Note: We are trying a new video hosting service. Please let us know in the comments if you have trouble viewing this.

Next week, we’ll begin our 13-week series sharing best practices from users like you at our 2012 Global TapRooT® Summit.
You won’t want to miss these innovative tips!

Root Cause Analysis Tip: TapRooT® Summit Session on Process Safety (Part 2)

April 4th, 2012 by

Last week, we shared Part 1 of Mark Paradies’ Summit talk on Process Safety.

Click here for Part 1.

He shared some of his experience in the Nuclear Navy and discussed the fact that large accidents like Deepwater Horizon could be prevented by following important process safety regulations.

This week, in Part 2, Mark discusses Admiral Rickover’s process safety principles and why they matter to your process safety improvement.

Come back next week for the third and final part of this series!

Update: Click here for Part 3.

Root Cause Analysis Tip: TapRooT® Summit Session on Process Safety (Part 1)

March 28th, 2012 by

This week’s Root Cause Analysis Tip comes straight from our 2012 Global TapRooT® Summit.

If you missed Mark Paradies’ session on “What Does Management Need to Know About Improving Process Safety?” don’t worry. We will be sharing it on the blog over the next three weeks.

Today is Part 1.

Mark began by showing this comedy clip on Deepwater Horizon:

(If you can’t see YouTube videos at work, click here.)

And continued on with his discussion on Process Safety:

(Having trouble seeing the videos? Refresh your browser page.)

Come back next Wednesday for Part 2 of his Process Safety Talk, in which he discusses Admiral Rickover’s “Big Three” nuclear navy safety regulations and more from his congressional testimony after the accident at Three Mile Island.


Update: Parts 2 and 3 have been posted!

Click here for Part 2.

Click here for Part 3.

What Management Needs to Know About Process Safety Improvement (or Why We Continue To Have Process Safety Accidents)

May 16th, 2011 by

I’m giving this talk in Bruges, Belgium for Total today and posted a PDF of the talk here so people who attended could get copies of the slides.

Click on the object below to download it…


As usual, the slides don’t tell the whole story. So if you would rather hear this talk, plan to attend the TapRooT® Summit on February 29 – March 2, 2012, in Las Vegas.

Success Story Contest: Stopping Future Accidents by Correcting Problems That Did Not Cause The Accidents Being Investigated

February 21st, 2011 by

There are four best practice entries published on this weblog in the success story contest (view all entries here).  Click the “Like” button for the entry you think should win an Apple iPad. All votes cast before Friday, March 4 at 6:00 p.m. EST will be tallied for the winner.  In the event of a tie, the in-house instructors at System Improvements will cast the tie-breaking votes.

Entry #2:  Stopping Future Accidents by Correcting Problems That Did Not Cause The Accidents Being Investigated

Submitted by: James Watson, Regional Specialist, System Safety Branch
FAA, Alaska


TapRooT® investigation often identify actions and conditions that didn’t cause the actual accident being evaluated but that could be significant and, if not corrected, could combine with other factors to cause a future accident.


These factors that the thorough analysis of TapRooT® helped identify are included in the presentation to management at the end of the talk (after the root cause analysis and corrective actions have been reviewed). This review includes explaining and discussing each of these potentially adverse factors with management. At a minimum, management is aware of these potentially adverse factors and the review often leads to discussion of additional corrective actions to address these issues.


Accidents that might have happened are avoided by implementing corrective actions for problems identified during a root cause analysis that didn’t cause that accident but could have cause additional accident and were corrected by proactive corrective actions.

Influencing Without Authority TapRooT® Session…. People at Work!

November 5th, 2010 by

Often people have the right ideas, the right plans and a need to get it done. Problem is that it is not always you who can drive the change. During the Summit we held a session that generated discussion on Stakeholders and Influence Centers.

Check out the multiple active group discussions during this workshop. Click on the Image to play the Video.

Sam 0212

For the link to the slides that generated these active discussions and a link to more formal analysis go here:

Bugs, Infection and TapRooT® Root Cause in Philadelphia

November 5th, 2010 by

When is the last you used TapRooT® Root Cause Analysis to investigate a Caterpillar?

The people below in our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training held in Philadelphia got to talk about this one.


What’s New In The TapRooT® Software?

November 4th, 2010 by

I have received several requests from our San Antonio Summit attendees for a copy of our ‘What’s New In The TapRooT® Software?” breakout session.  So without further ado, here it is…Click Here

Jeff Skiles – Co-Pilot of “Miracle on the Hudson” Landing – To Tell His Story at the Summit

September 7th, 2010 by

Skiles Jeff-1

I just got off the phone with Jeff Skiles who was the co-pilot of the US Airways flight that made an emergency landing in the Hudson River. It was a flight that could have had a tragic end but instead, everyone made it off the plane. After the conversation, I know we are going to have another great Keynote Speaker at the Summit.

Jeff said that he tells his story but provides some of the behind the scenes information that most people don’t know about. Information that helped them be successful that day but also might help you at your facility. The lessons aren’t just about aviation. They can be applied in any industry where things can go wrong and consequences can be severe.

So make sure that when you plan your trip, you plan to stay until the end of the Summit to hear Jeff’s talk. He’ll be speaking from 10:35-11:55 (followed by the TapRooT® Summit Charity Golf Tournament).

For the complete Summit schedule, see:

Mark’s Talk About the Heinrich Pyramid (Safety Pyramid) at the European Safety Committee of the Conference Board

June 1st, 2010 by

That’s me and the interested participants at the Conference Board…


Below is a copy of a PDF of the PowerPoint that I used.


BP/Tranocean Rig BOP Failure: The Smoking Gun Paper

May 7th, 2010 by

Little is known (or at least has been released) about the actual failure of the Blowout Preventer on the Deepwater Horizon. However, a technical paper (2003) has surfaced that may be a “smoking gun” if it is found that maintenance was deferred on the BOP to reduce costs of drilling.

Here’s a link to the paper (Earl Shanks, Transocean, presented at the Offshore Technology Conference, 2003):


Here’s one of the “smoking gun” quotes:

Because of the pressure on getting the equipment back to work, root cause analysis of the failure is generally not performed.”

Ah … a failure to perform root cause analysis to save time (and big bucks) during drilling.

Another quote:

In general, operating reliability (of the BOP) is maintained on rigs mostly through regular maintenance intervals rather than specifying a reliability of a system or a component to minimize maintenance.”

The article also said:

“… this is a very expensive approach, and it is also an opportunity to introduce human error into the system.”

Most of the paper is about ways to improve the design and reliability of Blowout Preventers. But the vultures are circling. And the smoking gun quotes above will mean trouble if it is found that any maintenance was skipped or if the BOP had a poor reliability record.

If maintenance was skipped and/or if the BOP had a poor reliability record, you will hear the cry that BP is once again trading lives (as at the BP Texas City explosion) and the environment (as at the corrosion related oil leaks in their pipeline at Prudhoe Bay). Actually, many don’t need evidence. They will start saying it already!

Could these Answers Affect your Investigations – Live Q&A Session with OSHA

April 29th, 2010 by

This is a link to an April 26 chat session with OSHA. Interesting answers.

Here is just one question and answer:

[Comment From Greg Hellman, BNAGreg Hellman, BNA: ]
OSHA has placed an injury and illness prevention program rule on its agenda for the first time. Could such a rule address musculoskeletal disorders in some way?
Monday April 26, 2010 1:27 Greg Hellman, BNA

David (OSHA):
The i2p2 standard is not a substitute for other OSHA standards. It provides a mechanism to achieve the culture change needed in this country to effectively address workplace safety and health issues. It will be the employer’s responsibility to identify all hazards in their workplace, which may include ergonomics, falls, amputations, electrocutions, work-related respiratory disease (such as occupational asthma), etc. The i2p2 standard simply provides a mechanism for employers to identify hazards; however, the control of those hazards will be required by existing OSHA standards and the general duty clause, as is currently the case.

New Approach to Root Cause Analysis Can Help Clear Up Misconceptions

April 26th, 2010 by

Quality Progress Magazine published a new article written by System Improvements’ President, Mark Paradies which can be read on the Quality Progress website:

You don’t have to be a member to access the article — free registration allows you access to ASQ’s “open-access” articles and case studies.

You can also find this article on page 32 of the April edition of Quality Progress magazine.

Article highlights:

• Cause and effect analysis has inherent limitations that may result in root cause analysis misconceptions and hinder problem-solving efforts.

• Problem solvers need help analyzing human performance issues.

• A new definition of root cause could help people realize a systematic process beyond cause and effect is needed for root cause analysis.

Monday Accident & Lessons Learned: TN OSHA Fatality Investigations

October 12th, 2009 by

“Lessons from TN OSHA Fatality Investigations” was a best practice session presented by Steve Hawkins at the 2009 TapRooT® Summit.

Taproot part 1 Hawkins

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We held our first on-site TapRooT Training in mid-1995. Shortly after the training we had another…


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