Category: Uncategorized

TapRooT® on Worldwide Business with Kathy Ireland®

March 6th, 2018 by

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®.

Everyday I Play Like A Champion!

February 28th, 2018 by

Did you enjoy Boaz’s speech? If so, here is his slide to keep you motivated.


Social Media Contest Update!

February 23rd, 2018 by

We have decided to add Instagram to the #taprootsummit contest. This gives you even more of an opportunity to win!

The same rules still apply:
1. You must have a Twitter or Instagram account (or both)
2. Follow either our Twitter or Instagram page (we encourage you to follow both)

3. Use the hashtag #taprootsummit when you post

The more you post on Instagram and Twitter, the greater your chances of winning.



You might be asking what should I post? Here are some suggestions:

Pictures of:

  • You and your friends at the Summit
  • Summit activities
  • 30th Anniversary Party
  • Keynote Speakers
  • Breakfast/Lunch Buffet

Or you can send us status updates about:

  • Your travels to the 2018 Global TapRooT® Summit
  • What you’ve learned/favorite Breakout Session
  • Fun and exciting things you’ve done around Knoxville, TN

Or simply just tell us about your experience at the 2018 Global TapRooT® Summit.

The more you tweet using the the hashtag #taprootsummit, the greater your chances of winning!

We will announce the winner Thursday, March, 1, just before Keynote Speaker Vincent Phipps. You must be PRESENT to win.

We will also have a live Twitter/Instagram feed projected in the Cumberland Concourse. Join in the fun and win a cool prize!

On the road with TapRooT®: Portland, Oregon

February 23rd, 2018 by

Join us in the Pacific Northwest!

From beginners to experts, TapRooT® Techniques are designed for everyone. In the span of our two-day course, you will learn the TapRooT® Essentials to find and fix the root causes of incidents, accidents, quality problems, near-misses, operational errors, hospital sentinel events, and many other types of problems. Upon course completion, attendees will receive a certificate and a 90-day subscription to TapRooT® VI, the online software service. Most importantly, you will have the advantage of professional training in your wheelhouse and on your resume!

For the Two-Day TapRooT® Techniques course, we’ll gather at Courtyard by Marriott Portland City Center on March 21-22. The centrally located Courtyard offers just-out-the-door convenience to enjoy Portland’s local highlights, or to simply take a refreshing walk. You can also discover gems to explore on our Portland Pinterest.

Attendees should bring safety incidents or quality issues from their facility for a team exercise. These may be either written reports or, alternately, you may have knowledge of an incident without a written report. We’ll divide into teams of 2-4 people, with each team analyzing a different problem.

Register here to advance your professional development.

Twitter Contest

February 20th, 2018 by

This year at the 2018 Global TapRooT® Summit we will be hosting a Twitter contest. To enter to win you will need to have a twitter account, follow our Twitter page (@TapRooT_RCA), and use the hashtag #taprootsummit.

You might be asking what should I post!? Well here are some suggestions.

Pictures of:

  • You and your friends at the Summit
  • Summit activities
  • 30th Anniversary Party
  • Keynote Speakers
  • Breakfast/Lunch Buffet

Or you can send us status updates about:

  • Your travels to the 2018 Global TapRooT® Summit
  • What you’ve learned/favorite Breakout Session
  • Fun and exciting things you’ve done around Knoxville, TN

Or simply just tell us about your experience at the 2018 Global TapRooT® Summit.

The more you tweet using the the hashtag #taprootsummit the greater your chances of winning!

We will announce the winner Thursday March, 1 before the Keynote Speaker Vincent Phipps. You must be PRESENT to win.

Emmett – Newest Addition to the TapRooT® Family

February 1st, 2018 by

Proud father Garrett Boyd sent us this photo of his newborn son, Emmett…


Send Garrett congratulations by leaving comments here…


New Name Gives Nod to 1982 Knoxville World’s Fair

January 31st, 2018 by

Visitors and Knoxvillians will enter an updated building and a new phase in the life of the formerly named Knoxville Convention and Exhibition Center, now known as the World’s Fair Exhibition Hall. The area underneath the downtown Holiday Inn is undergoing a 2.1 million renovation, to include a new roof and remodeled restrooms. The rename and remodel of the hall will be celebrated with a new logo displaying the 1982 World’s Fair flame and international flags in Rubik’s Cube fashion.

The 2018 Global TapRooT® Summit will be hosted in Knoxville Convention Center, February 26 – March 2. Register now to change the way you do business and solve problems.

Monday Accidents & Lessons Learned

January 22nd, 2018 by

A passenger train leaving London Waterloo station and traveling at about 13 mph (21 km/h) collided with a stationary engineering train. There were no injuries, but both trains were damaged. Glean more insights from the London Waterloo rail accident investigation here.

Who’s Coming to the 2018 Global TapRooT® Summit in Knoxville, TN?

January 18th, 2018 by


It’s still to early to make a final attendance list but I thought people might be interested in a list of the companies who have signed people up early to attend the 2018 Global TaoRooT® Summit.

American Water
Champion Technologies
Energy Systems Group
First Energy
Flint Hills Resources
IAP Worldwide
Lotte Chemical
Marathon Petroleum
Matrix North American Construction
Nalco Chemicals
Nine Energy Services
North Star Generation
Parker Drilling
Patten Energy
PNM Resources
Prairie State Generating
Saudi Aramco
SBM Offshore
TD Williamson
Terango Gold
United Tehnologies
Vancouver Airport Authority

That’s a sample (not a complete list). The list grows every day.

If you are waiting to sign up, STOP waiting. CLICK on this LINK and register NOW!

What do people who have attended the Global TapRooT® Summit in the past have to say about it? here are just a few people sharing their experience…

5 Reasons Why You Should Attend the Pre-Summit Course: Getting the Most from Your TapRooT® VI Software

December 19th, 2017 by


  1. Learn to create your own Custom Tab and Custom Fields. Creating custom tabs and fields is a very powerful feature in the software and this course will go into great detail on how to customize these for your business needs.
  2. Learn to create your own Custom Reports and Report Templates. The TapRooT® VI software does not assume to know exactly what reports you want to see and share with your team members. This course will teach you how to build reports that contain specifically what you want and how to create and share the same templates with other users.
  3. Learn to use the redesigned Optional Techniques. Do you know that the software contains tools and techniques that can help you build better SnapCharT®s and more thoroughly investigate your incidents? This course will show you how to use Safeguard Analysis, Change Analysis, Equifactor® and CHAP.
  4. Learn the Administrative functions available to give your users more options. This course will go into great detail on the new administrative features including Notifications, Maintenance Mode and Custom Equifactor®.
  5. Learn how to use the Trending features to understand where opportunities exist in your business. The new dashboard is customizable and offers hundreds of options to look at root cause, location and classification trends. You will also learn to export custom data to create additional custom reports.

Come join us February 26th and 27th before the Global TapRooT® Summit to get the most from your TapRooT® VI Software!

CLICK HERE to register today.

Hack of safety system causes plant shutdown …

December 18th, 2017 by

Jim Whiting (TapRooT® Instructor) sent me this link to a plant shutdown caused by a hack of a safety system computer code.

There isn’t a lot of specifics in the article but it does make one wonder about the applicable corrective actions and how they should be applied across the whole industry.

Software Track at the 2018 Global TapRooT® Summit

December 7th, 2017 by


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.

TapRooT® 2 Day in the Music City

November 29th, 2017 by

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!

What’s Wrong with this Data?

March 20th, 2017 by

Below are sentinel event types from 2014 – 2016 as reported to the Joint Commission (taken from the 1/13/2017 report at

Summary Event Data

 Reviewing this data, one might ask … 

What can we learn?

I’m not trying to be critical of the Joint Commissions efforts to collect and report sentinel event data. In fact, it is refreshing to see that some hospitals are willing to admit that there is room for improvement. Plus, the Joint Commission is pushing for greater reporting and improved root cause analysis. But, here are some questions to consider…

  • Does a tic up or down in a particular category mean something? 
  • Why are suicides so high and infections so low? 
  • Why is there no category for misdiagnosis while being treated?

Perhaps the biggest question one might ask is why are their only 824 sentinel events in the database when estimates put the number of sentinel events in the USA at over 100,000 per year.

Of course, not all hospitals are part of the Joint Commission review process but a large fraction are.  

If we are conservative and estimate that there should be 50,000 sentinel events reported to the Joint Commission each year, we can conclude that only 1.6% of the sentinel events are being reported.

That makes me ask some serious questions.

1. Are the other events being hidden? Ignored? Or investigated and not reported?

Perhaps one of the reasons that the healthcare industry is not improving performance at a faster rate is that they are only learning from a tiny fraction of their operating experience. After all, if you only learned from 1.6% of your experience, how long would it take to improve your performance?

2. If a category like “Unitended Retention of a Foreign Body” stays at over 100 incidents per year, why aren’t we learning to prevent these events? Are the root cause analyses inadequate? Are the corrective actions inadequate or not being implemented? Or is there a failure to share best practices to prevent these incidents across the healthcare industry (each facility must learn by one or more of their own errors). If we don’t have 98% of the data, how can we measure if we are getting better or worse? Since our 50,000 number is a gross approximation, is it possible to learn anything at all from this data?

To me, it seems like the FIRST challenge when improving performance is to develop a good measurement system. Each hospital should have HUNDREDS or at least DOZENS of sentinel events to learn from each year. Thus, the Joint Commission should have TENS or HUNDREDS of THOUSANDS of sentinel events in their database. 

If the investigation, root cause analysis, and corrective actions were effective and being shared, there should be great progress in eliminating whole classes of sentinel events and this should be apparent in the Joint Commission data. 

This improved performance would be extremely important to the patients that avoided harm and we should see an overall decrease in the cost of medical care as mistakes are reduced.

This isn’t happening.

What can you do to get things started?

1. Push for full reporting of sentinel events AND near-misses at your hospital.

2. Implement advanced root cause analysis to find the real root causes of sentinel events and to develop effective fixes that STOP repeat incidents.

3. Share what your hospital learns about preventing sentinel events across the industry so that others will have the opportunity to improve.

That’s a start. After twelve years of reporting, shouldn’t every hospital get started?

If you are at a healthcare facility that is

  • reporting ALL sentinel events,
  • investigating most of your near-misses, 
  • doing good root cause analysis, 
  • implementing effective corrective actions that 
  • stop repeat sentinel events, 

I’d like to hear from you. We are holding a Summit in 2018 and I would like to document your success story.

If you would like to be at a hospital with a success story, but you need to improve your reporting, root cause analysis and corrective actions, contact us for assistance. We would be glad to help.

Simple Root Cause Analysis (Don’t Settle!)

February 23rd, 2017 by


RCA, Root Cause analysis, 5-why, 5-whys
OK, show of hands:

How many companies are using TapRooT® for their “hard,” “high-risk” incident analyses and using something like 5-Whys for the “simple” stuff?  Yep, I thought so.  A lot of companies are doing this for various reasons. I’ll get into that more in a minute.

Now, another poll:

How many of you are performing effective root cause analyses on your “important,” “high-consequence” investigations, and performing nearly useless analyses on the “easy” stuff?  Of course, you know this is really exactly the same question, but you’re not as comfortable raising your hand the second time, are you?

Those of you that follow this blog have already read why using inferior RCA methods don’t work well, but let me recap.  I’m going to talk about 5-Whys specifically, but you can probably insert any of your other, less-robust analysis techniques here:


  • It does not use an expert system.  It relies on the investigator to know what questions to ask.
  • Because of this, it allows for investigator bias.  If you are a training person, you will (amazingly enough) end up with “training” root causes.
  • The process does not rely on human performance expertise.  Again, it relies on the skill of the investigator.  Yes, I know, we’re all EXCELLENT investigators!
  • It does not produce consistent results.  If I give the same investigation to 3 different teams, I always get 3 different sets of answers.
  • There is no assistance in developing effective corrective action.  When 80% of your corrective actions fall into the “Training” “Procedures” and “Discipline” categories, you are not really expecting any new results, are you?

So, knowing this to be true, why are we doing this?  Why are we allowing ourselves to knowingly get poor results?

  • These are low risk problems, anyway.  It doesn’t matter if we get good answers (Why bother, then?)
  • It’s quick.  (Of course, quickly getting poor results just doesn’t seem to be an effective use of your time.)
  • It’s easy (to get poor results).
  • TapRooT® takes too long.  Finally, an answer that, while not true, at least makes sense.

So what you’re really telling me is that if TapRooT® were just easier to use, you would be able to ditch those other less robust methods, and use TapRooT® for the “easy” stuff, too.

Guess what?  We’ve now made TapRooT® even easier to use!  The 7-step TapRooT® process can now be shortened for those “easy” investigations, and still get the excellent results you’re used to getting.

Simple RCA, TapRooT, root cause analysisWe now teach the normal 7-Step method for major incidents, where you need the optional data-collection tools.  However, we are now showing you how to use TapRooT® in low to medium-risk investigations.  You are still using the tools that make TapRooT® a great root cause analysis tool.  However, we show you how to shorten the time it takes to perform these less-complex analyses.

The 2-Day TapRooT® Incident Investigation Course concentrates on these low to medium-risk investigations.  The 5-Day TapRooT® Advanced Team Leader Course teaches both the simple method, but also teaches the full suite of TapRooT® tools.

Don’t settle for poor investigations, knowing the results are not what you need.  Take a look at the new TapRooT® courses and see how to use the system for all of your investigations.  You can register for one of these courses here.

Do Your Folks Know What to Keep After an Accident?

February 22nd, 2017 by


A failure occurs. It could be:

  • a safety related accident
  • an equipment failure
  • a patient safety event (sentinel event)
  • a quality issue
  • a shipping screw up
  • a cost overrun
  • a process safety related near-miss

What people do next can make a world of difference.

First, is the failure (incident or near-miss) reported? Or is it covered up?

If you are reading this you probably think that your company should learn from its mistakes to keep the mistakes from happening again. (Or to keep something even worse from happening – like the picture above.)

But if mistakes and failures are hidden, learning is unlikely.

People must know that it is safe to report a problem and that, once a problem is reported, something will be done to improve the process to make the problem go away.

Punishing the person who reported the problem or punishing someone else involved in the failure IS NOT the kind of action that will promote more reporting of failures.

OK … You have established a culture where the reporting of problems is not punished. You may even have a culture where the reporting of problems is an expected part of how you do business. NOW WHAT?

Do people know how to preserve the evidence of the failure so that an effective root cause analysis can be performed?

You might be surprised that most folks don’t know how to preserve the scene of an accident.

They don’t know that disassembling broken equipment may destroy the evidence of why the equipment broke.

They may not collect the names of everyone involved (including contractors and first responders).

They may “clean things up” to get back to normal housekeeping standards.

They may let vital fluid samples slip away.

They may even collect “souvenirs” to take home.

Reporting the failure really doesn’t help if the evidence of the failure is destroyed before the root cause analysis starts.

What are you doing to train your supervisors to preserve the scene of a failure?

I have two suggestions.

1. Have training for them on evidence collection and interviewing.

We have a TapRooT® Course that can help supervisors secure the scene of an accident and have a much better idea of what they need to do when responding to a failure.

The course can be customized to teach just the information that you think your supervisors need.

The complete 2-Day TapRooT® Effective Interviewing & Evidence Collection Course has essential information that supervisors need to stop evidence destruction and help conduct interviews of those involved. See the course outline at:

Barb Phillips, the course designer, will be happy to talk to you about customizing the course for your supervisors to give them the knowledge and practice that they need to be ready to effectively respond to a failure. To talk to Barb, call 865-548-8990. Or email her by using this LINK.

2. Your equipment folks need training in equipment troubleshooting and failure analysis.

We have another course designed for equipment troubleshooters to help them avoid the destruction of evidence when they respond to an equipment failure. The 2-Day Equifactor® Equipment Troubleshooting and TapRooT® Root Cause Analysis Course will help them develop a troubleshooting plan that will preserve the evidence they need to troubleshoot the problem and find the problem’s root causes.

Again, the Equifactor® Course can be customized to meet the needs of your troubleshooters. Call Ken Reed, the course creator, at 865-539-2139 to discuss ways to make your training targeted to your workforce. Or contact him by e-mail at this LINK.

Whatever you do … DON’T sit back and wait for the next accident and assume that your folks will respond appropriately. I can assure you that if hoping for the best is your strategy … you will be sadly disappointed.

Tip for Safety and Environmental Regulators – If a Refinery is being sold, INSPECT!

February 15th, 2017 by


Saw an interesting article in Hydrocarbon Processing titled:

Rosneft faces $100-MM bill to boost safety at Bashneft refineries

That reminded me of the Amoco refineries that were sold to BP and had a horrible safety record.

Regulators should have a red flag for any assists covered under a PSM program. If they are being sold, INSPECT!

Perhaps this could stop management from excessive cost cutting pre-sale to boost the bottom line at the expense of safety and the environment.

TapRooT® Users Ahead of California PSM Regulations

February 14th, 2017 by

You may have reviewed the new regulations for process safety at California refineries. This is a major change to the standard PSM rules in the USA for California refineries. 

Here is the section from the “Incident Investigation” portion of the rule…

– – – 

(o) Incident Investigation – Root Cause Analysis.

  1. The employer shall develop, implement and maintain effective written procedures for promptly investigating and reporting any incident that results in, or could reasonably have resulted in, a major incident.
  2. The written procedures shall include an effective method for conducting a thorough Root Cause Analysis.
  3. The employer shall initiate the incident investigation as promptly as possible, but no later than 48 hours following an incident. As part of the incident investigation, the employer shall conduct a Root Cause Analysis.
  4. The employer shall establish an Incident Investigation Team, which at a minimum shall consist of a person with expertise and experience in the process involved; a person with expertise in the employer’s Root Cause Analysis method; and a person with expertise in overseeing the investigation and analysis. The employer shall provide for employee participation pursuant to subsection (q). If the incident involved the work of a contractor, a representative of the contractor’s employees shall be included on the investigation team.
  5. The Incident Investigation Team shall implement the employer’s Root Cause Analysis method to determine the initiating causes of the incident. The analysis shall include an assessment of management system failures, including organizational and safety culture deficiencies.
  6. The Incident Investigation Team shall develop recommendations to address the findings of the Root Cause Analysis. The recommendations shall include interim measures that will prevent a recurrence or similar incident until final corrective actions can be implemented.
  7. The team shall prepare a written investigation report within ninety (90) calendar days of the incident. If the team demonstrates in writing that additional time is needed due to the complexity of the investigation, the team shall prepare a status report within ninety (90) calendar days of the incident and every thirty (30) calendar days thereafter until the investigation is complete. The team shall prepare a final investigation report within five (5) months of the incident.
  8. Investigation reports shall include:
    (A) The date and time of the incident;
    (B) The date and time the investigation began;
    (C) A detailed description of the incident;
    (D) The factors that caused or contributed to the incident, including direct causes, indirect causes and root causes, determined through the Root Cause Analysis;
    (E) A list of any DMR(s), PHA(s), SPA(s), and HCA(s) that were reviewed as part of the investigation;
    (F) Documentation of relevant findings from the review of DMR(s), PHA(s), SPA(s) and HCA(s);
    (G) The Incident Investigation Team’s recommendations; and,
    (H) Interim measures implemented by the employer.
  9. The employer shall implement all recommendations in accordance with subsection (x).
  10. The employer shall complete an HCA in a timely manner for all recommendations that result from the investigation of a major incident. The employer shall append the HCA report to the investigation report.
  11. Investigation reports shall be provided to and upon request, reviewed with employees whose job tasks are affected by the incident. Investigation reports shall also be made available to all operating, maintenance and other personnel, including employees of contractors where applicable, whose work assignments are within the facility where the incident occurred or whose job tasks are relevant to the incident findings. Investigation reports shall be provided to employee representatives and, where applicable, contractor employee representatives.
  12. Incident investigation reports shall be retained for the life of the process unit.

– – – 

TapRooT® Users already find management system, organizational, and cultural related root causes or generic causes that contributed to incidents they investigate. They also know about the hierarchy of controls (part of HCA analysis) and Safeguard Analysis (part of SPA) when developing corrective actions. 

TapRooT® has always been ahead of its time in finding human factors related causes of incidents. Thus, TapRooT® Root Cause Analysis fits well with the Human Factors section of the California regulation…

– – –

(s) Human Factors.

  1. The employer shall develop, implement and maintain an effective written Human Factors program within eighteen (18) months following the effective date of this section.
  2. The employer shall include a written analysis of Human Factors, where relevant, in major changes, incident investigations, PHAs, MOOCs and HCAs. The analysis shall include a description of the selected methodologies and criteria for their use.
  3. The employer shall assess Human Factors in existing operating and maintenance procedures and shall revise these procedures accordingly. The employer shall complete fifty (50) percent of assessments and revisions within three (3) years following the effective date of this section and one hundred (100) percent within five (5) years.
  4. The Human Factors analysis shall apply an effective method in evaluating the following: staffing levels; the complexity of tasks; the length of time needed to complete tasks; the level of training, experience and expertise of employees; the human-machine and human-system interface; the physical challenges of the work environment in which the task is performed; employee fatigue and other effects of shiftwork and overtime; communication systems; and the understandability and clarity of operating and maintenance procedures.
  5. The Human Factors analysis of process controls shall include:
    (A) Error-proof mechanisms;
    (B) Automatic alerts; and,
    (C) Automatic system shutdowns.
  6. The employer shall include an assessment of Human Factors in new operating and maintenance procedures.
  7. The employer shall train operating and maintenance employees in the written Human Factors program.
  8. The employer shall provide for employee participation in the Human Factors program, pursuant to subsection (q).
  9. The employer shall make available and provide on request a copy of the written Human Factors program to employees and their representatives and to affected contractors, employees of contractors, and contractor employee representatives, pursuant to subsection (q).

– – – 

These initial drafts of the regulation have been slightly modified at a public hearing last Fall. The modifications can be viewed at:

The California Occupational Safety and Health Standards Board is set to review the revisions and comments on a meeting being held after the comment period expires on March 3, 2017.  

While the new rule is being modified prior to adoption, California TapRooT® Users should be happy to know that they are already using a system that helps them meet and exceed the regulation being developed.

EPA to Require Root Cause Analysis in RMP Required Investigations

February 13th, 2017 by

The EPA announced in December their intention to finalize a new r Risk management Plan rule for facilities with highly hazardous chemicals. Of interest to readers of this blog, the new proposal for incident investigations requires root cause analysis using a recognized method. 

Here is the proposed language:


(a) The owner or operator shall investigate each incident that:

  1. Resulted in a catastrophic release (including when the affected process is decommissioned or destroyed following, or as the result of, an incident); or
  2. Could reasonably have resulted in a catastrophic release (i.e., was a near miss).

(b) A report shall be prepared at the conclusion of the investigation. The report shall be completed within 12 months of the incident, unless the implementing agency approves, in writing, an extension of time. The report shall include:

  1. Date, time, and location of incident;
  2. A description of the incident, inchronological order, providing all relevant facts;
  3. The name and amount of the regulated substance involved in the release (e.g., fire, explosion, toxic gas loss of containment) or near miss and the duration of the event;
  4. The consequences, if any, of the incident including, but not limited to: injuries, fatalities, the number of people evacuated, the number of people sheltered in place, and the impact on the environment;
  5. Emergency response actions taken;
  6. The factors that contributed to the incident including the initiating event, direct and indirect contributing factors, and root causes. Root causes shall be determined by conducting an analysis for each incident using a recognized method; and
  7. Any recommendations resulting from the investigation and a schedule for addressing them.

With the new administrations halt on new regulations, I’m not sure what will happen with this modification to an existing rule … so keep an eye out for the publication in the Code of Federal Regulations.

One last note if you were wondering … TapRooT® Root Cause Analysis is a recognized method.

New! New! New!

January 17th, 2017 by

We have been working hard to make TapRooT® even better. Therefore, we have NEW things to share.

Books FannedOut


We have three new books that are available and three more that will be coming out in the first quarter. They are part of the new nine book set that will all be out by the end of 2017.

To see what is available now, CLICK HERE.



We’ve been updating our TapRooT® Training. Every course has had major improvements. Of course, the new courses include the new books, but there is much more that’s been improved to make TapRooT® easier to use and more effective. To find out more about our TapRooT® Courses, CLICK HERE.



Have you had a look at our new Version VI TapRooT® Software? It’s cloud-based and is device independent. Use it on your PC, Mac, or any tablet. CLICK HERE for more info.


The old TapRooT® Books, training, and software were good. The NEW TapRooT® Books, Training, and Software are even better. Don’t miss out in the advances in TapRooT® Technology. Get the latest by clicking on the links above and updating your technology.

Also, as more new books, courses, and software improvements are released as the year progresses, we will let you know by posting information here. Keep watch and keep up with the latest in advanced root cause analysis.

Are You Up to Date? NEW Root Cause Analysis Books!

November 9th, 2016 by

We are making a major move forward in 2017. There will be a whole NEW basis for TapRooT® when we are done writing the nine new books that will document the TapRooT® System.

Root Cause Books

Some of the new TapRooT® Books are out and are available on the TapRooT® Web Site.

What is out so far?

If you would like to get the TapRooT® Essentials Book and The Major Investigation Book at the same time, you can get them for a discount by CLICKING HERE.

These new book sets will include the latest Root Cause Tree® (2015), Root Cause Tree® Dictionary (2016) and Corrective Action Helper® Guide (2016).

By the end of the year we are hoping to also have available:

  • Book 1: The TapRooT® Root Cause Analysis Philosophy – Changing the Way the World Solves Problems
  • Book 5: Using Equifactor® Troubleshooting Tools and TapRooT® Root Cause Analysis to Improve Equipment Reliability
  • Book 7: TapRooT® Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills

Also, watch for our translations of these books in Spanish, Portuguese, German, and French. (Not out yet but we are working on it.)

We are excited about the advances we have made and how usable the new books are.


If you want great root cause analysis for a fast, simple investigation, you need to read:

We have made major strides in making TapRooT® easy to use. We even have a new five step process for doing a low-to-medium risk incident investigation.


Not all investigations are simple. We knew we needed to write a book that explained the whole TapRooT® process and tools for investigating high potential and high risk incidents. Therefore we wrote:

There is excellent new materials that completely document the entire 7-step TapRooT® System and all the TapRooT® Tools.


Do you want to get ahead of accidents, incidents, and quality issues? Then you need:

This book details the way you can apply the TapRooT® Tools to your proactive improvement efforts – especially audits.

Each of these books are tied to new courses.

The TapRooT® Essentials Book is tied to our 2-Day TapRooT® Root Cause Analysis Training.

The TapRooT® Major Investigations Book is tied to the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. The course reviews a copy of the TapRooT® Essentials Book.

And finally, the Using TapRooT® for Audits Book is linked to our 2-Day TapRooT® four Audits Course.

We hope you will find these books (and courses) as helpful as others have.

Technically Speaking – Dashboard Widgets

October 13th, 2016 by

What’s a widget you ask?? If you would have asked me this question when I was a child, I would have told you that Widget was the name of my family pet cat. But today, the term widget means something else to me in regards to software. A widget is a small application within a webpage that provides useful information. You may be familiar with widgets that you use on your iPhone or Smartphone.

Well in TapRooT® VI, widgets exist to provide valuable trending data on your incidents, investigations, audits, root causes and corrective actions. Currently, if you were to visit the DASHBOARD menu, you would find just 4 basic widgets. But I am excited to announce that in our near future release we have COMPLETELY enhanced this dashboard with a variety of widgets and custom options to help meaningfully display your data.

Want to know which Basic Cause Categories, Near Root Causes or Root Causes are your biggest offenders? Want to know which locations or classifications have the most issues? Want to know how many complete, incomplete or past due Corrective Action tasks you have? These dashboard widgets will let you know. There are almost 25 widgets that can be viewed in over 70 combination display types to help you focus on exactly what sort of information you want to see. Take a look.

dashboard widgets


You can choose from a variety of display chart types including Table Chart, Pie Chart, Horizontal or Vertical Bar Charts, Line Charts AND Pareto Charts.

You can filter by date range, location and classification to really drill down to that level of detail that you may want to understand.

dashboard filter

Want to print a copy of your charts? You can export them to PDF and save or print to share with others.

Customize your dashboard to display your most frequently displayed widgets every time you visit the dashboard.

Slice it, dice it, anyway you want to see it. These little widgets pack a lot of big power and information. You can look forward to seeing these new features VERY soon!


Technically Speaking is a weekly series that highlights our TapRooT® VI software and occasionally includes a little Help Desk humor.

Remember, just because it’s technical, doesn’t mean it has to be complicated!

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If you are a TapRooT® User, you may think that the TapRooT® Root Cause Analysis System exists to help people find root causes. But there is more to it than that. TapRooT® exists to: Save lives Prevent injuries Improve product/service quality Improve equipment reliability Make work easier and more productive Stop sentinel events Stop the …

Four years ago I was an incident investigator, an incident reviewer, and an investigation techniques…

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