April 15, 2020 | Mark Paradies

The Best Root Cause Analysis Toolkit Review

Toolkit for Root Cause Analysis

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What’s the best for root cause analysis toolkit? Read on and see. We will outline the tools used in what we think is the best root cause analysis toolkit! Read about:

  • Defining a root cause
  • A process to connect your tools
  • An “understanding what happened” tool
  • Optional evidence collection tools
  • A Causal factor definition tool
  • A guided root cause analysis tool
  • A Generic Cause analysis tool
  • A tool to present your results
  • How the best root cause analysis toolkit was developed

After you read about this toolkit, you will understand more about the fundamentals of root cause analysis and incident investigation, and you will want to order a book or sign-up for a course.

Before We Built an RCA Toolkit, We Had to Define a Root Cause

Before you can build a root cause analysis toolkit, you have to define what you are looking for – a root cause.

Back in 1985, when David Busch and I started looking for ways to find root causes, we weren’t the first to define a “root cause.” There was already a dictionary definition. The on-line Collins Dictionary defines a root cause as:

“The fundamental reason for the occurance of a problem.”

The Collins Dictionary says that the first recorded usage of “root cause” was sometime in the late 1800s and that the term “root cause” is one of the 30,000 most used words in the dictionary.

But we thought the definition needed to be more specific. Therefore, we started developing our own definition. Our first definition, first published in 1986, is shown below…

ROOT CAUSE

The most basic cause (or causes)
that can reasonably be identified
that management has control to fix.

We quickly found that not everyone agrees with this definition. However, several key ideas sprung from the definition that became the bedrock upon which the TapRooT® Root Cause Analysis System was built (and from which many other definitions were developed across many industries).

FIRST, when one finds a root cause, one has found something that will fix the problem. This is a key because it keeps one looking for a FIXABLE SOLUTION.

SECOND, our definition targets problems that are within management’s grasp to fix. For example, one might say that the root cause of a fall is gravity. This would not be a root cause by our definition because management can’t fix gravity.

THIRD, our definition helps answer the always troubling question of how much investigative effort is enough. This question really comes down to a trade-off between a “REASONABLE” effort (usually defined as the least possible effort) and finding the “MOST BASIC” cause(s) (sometimes seen as a never-ending quest if people can’t agree on the definition of a “basic cause”). The final arbitrator between these two competing priorities (timeliness and completeness) is the requirement to find fixable causes that, when corrected, will prevent the incident’s recurrence. Therefore, an investigator has expended a “reasonable” effort if one has identified the FIXABLE CAUSES OF AN INCIDENT.

FOURTH, the definition implies that a problem MAY HAVE MORE THAN ONE ROOT CAUSE. In our early experience investigating and reviewing hundreds of incidents we found that, on average, incidents had two to three root causes per simple incident (a simple incident is one with one or two Causal Factors). In our experience with more complex incidents in more complex systems (with multiple Safeguards and multiple Causal Factors in the incident), we often found 10 or more root causes (things that can be improved) in a single, complex incident.

Allowing for multiple root causes stops arguments over which cause is the “rootiest” of the root causes. Any cause for a problem that fits the definition is one of the problem’s root causes.

Our definition was the jumping-off point in the search for a toolkit that helps problem solvers find fixable root causes.

But we didn’t stop with our 1986 definition. We continuously improved it. By 2006, we decided to completely overhaul the definition to make it much more positive and focus on best practices that could stop problems from occurring. The modern definition we now use is:

MODERN Definition OF A ROOT CAUSE

The absence of a best practice
or the failure to apply knowledge
that would have prevented the problem.

Rarely does an accident happen that we didn’t already know how to prevent it. The absence of a best practice or the failure to apply the knowledge that we already possess allows an accident to occur.

All the definitions we developed gave us guidance when developing a root cause analysis toolkit (a systematic process to find root causes). It helped us develop our tools and build them into a robust root cause analysis process.

You Need A Process That Connects Your Tools

When we started looking for root cause analysis tools and develop our own tools, we thought of the tools as handy tools that a master root cause analyst would use. The analyst would know which ones to use and when. The tools weren’t connected.

By the time we wrote the first TapRooT® Manual in 1991 (shown below), we realized that the tools were connected – part of a process.

TapRooT® ® Manual

By 2015 when we started writing our most recent ten-book set, we had developed three processes. One for simple incidents and one for major accidents. The simple incident process is on the left and the major accident process is on the right.

The third process was a modification to the simple incident process to make a process for investigating equipment failures (shown below).

Our goal was to make it easy to investigate simple incidents and equipment failures, and also, to provide all the tools you needed for major accidents.

The processes provide the investigator guidance for which tools to use when.

A Tool to Help You Understand What Happened

One of the first tools used in any investigation (simple, equipment, or major) is the SnapCharT® Diagram. The SnapCharT® Diagram provides a place to display the information you collect and understand what happened. An example of a SnapCharT® is shown below…

SnapCharT® with Causal Factors

We think it is essential to understand what happened BEFORE you try to determine WHY it happened (the root causes).

Failure to understand what happened before you start asking why is one of the major drawbacks of many root cause analysis tools.

Optional Evidence Collection Tools

The TapRooT® 7-Step Major Investigation Process has three optional tools to help investigators collect information about an incident/accident. They are:

  • Equifactor®
  • Change Analysis
  • Critical Human Action Profile (CHAP)

They were added to the process to provide investigators with specialized tools for particular types of investigations.

Equifactor® was developed specifically for the TapRooT® System with the help of equipment reliability expert Heinz Bloch to help investigators troubleshoot equipment failures and understand the underlying physical causes.

Equifactor® Troubleshooting Guide

Change Analysis was adopted for use in the TapRooT® System by permission of the  System Safety Development Center to help people analyze how changes could have led to an incident.

CHAP was developed for use by the US Nuclear Regulatory System and the TapRooT® System to help investigators collect information and understand human errors that led to incidents.

In the TapRooT® Advanced Root Cause Analysis Team Leader Training, each of these techniques is reviewed in detail and demonstrated in an example.

Also the TapRooT® Advanced Root Cause Analysis Team Leader Training and the 2-Day Effective Interviewing & Evidence Collection Course offer techniques to effectively conduct interviews (the 15-Step Cognitive Interviewing Process) and guidance for evidence collection and preservation. These techniques help make the tools and processes more effective.

A Tool to Define Causal Factors

One of the newest tools in the TapRooT® Toolkit is the Causal Factor Worksheet. There are actually four of these worksheets. There are worksheets for incidents related to:

  • Safety
  • Quality
  • Equipment Failure
  • Patient Safety

The TapRooT® Safety Causal Factor Worksheet (copyright © System Improvements, used by permission) is shown below…

Safety Causal factor Worksheet

These worksheets help investigators more accurately and completely define the Causal factors that led to the incident/accident. They are used for simple incidents, equipment failure related incidents, and major accidents. If you are already a TapRooT® User and you would like to find out more about using these worksheets, sign up for The New Causal Factor Worksheet Webinar. The next webinar is coming up on April 29th. Register HERE.

A Tool to Find Root Causes

Perhaps the most powerful tool at the heart of the TapRooT® Toolkit is the TapRooT® Root Cause Tree®.

What does the Root Cause Tree® do for an investigator? It guides the investigator from a Causal Factor to the Causal Factor’s root causes. Guided root cause analysis is a much more powerful way to find root causes. Read more about guided root cause analysis at THIS LINK.

guided wagon train

A Tool to Help Find Generic Causes

A Generic Cause is:

GENERIC CAUSE
The systemic cause that allows a root cause to exist.
Fixing the Generic Cause eliminates whole classes
of specific root causes.

Finding Generic Causes is step five in the TapRooT® 7-Step Major Investigation Process. It is also an optional step in the simple investigation process. The Corrective Action Helper® Guide/Software Module is used to help the investigator in this process.

A Tool to Develop Corrective Actions

The main purpose of the Corrective Action Helper® Guide/Software Module is you help investigators suggest effective corrective actions to prevent the recurrence of incidents.

The Guide has four major sections for each root cause on the Root Cause Tree®. They are:

  • Check: The first step is to check that you have truly identified a root cause.
  • Corrective Action Ideas: Provides suggestions for developing effective corrective actions.
  • Generic Cause Corrective Action Ideas: Provides suggestions for addressing the Generic Causes you identified.
  • References: Provides references to learn more about this root cause.

A Tool to Help You Present Your Results

Investigators usually present the results of their investigation to management. The SnapCharT® Diagram turns out to be a great tool to explain what you have found.

In addition, the TapRooT® Software provides a preset report to should your Causal factors and Corrective Actions.

Why Is the TapRooT® System the Best Root Cause Analysis Toolkit?

We spent years developing the first TapRooT® System and Manual. We’ve spent decades improving the system and books.

Above are the first three generations of TapRooT® Documentation. In 2015, we started writing the 10-book set that we complete in 2020 (watch for your opportunity to purchase the set at a discount to be announced soon or buy the books you need individually at THIS LINK).

The TapRooT® System started with research into root cause analysis best practices and the human factors research behind why people make mistakes. This information was used to develop a system that was tested in the field and reviewed by experts. Over the next 30 years System Improvements refined the system by testing, feedback from trainees, and advice from the 50-member TapRooT® Advisory Board that is made up of users from different industries from around the world. To read more about the history of the development of TapRooT®, visit the HISTORY PAGE on this website. It explains the over 30 years of research and development and the scientific basis of the TapRoot® System.

We based the system on proven engineering experience and human factors research that was developed into a guided root cause analysis process and tools that have been thoroughly tested, improved, and reviewed and have gone through years of continuous improvement and software development to make the system even more usable. This process yielded the world’s best root cause analysis toolkit. A single system, with software, that covers all your root cause analysis needs.

How Can You Learn About the TapRooT® Root Cause Analysis Toolkit?

While you are working from home, perhaps a book is the best way to get started. Book 4: TapRooT® Root Cause Analysis for Major Investigations covers the process and tools for major investigations.  Or you could buy Book 3 (Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents) and Book 4 at the same time at THIS LINK.

If you can wait until June, we will start providing our Public TapRooT® Training again. Our upcoming 2-Day TapRooT® Root Cause Analysis Courses will be held at the following locations on the following dates:

June 1-2 … Calgary, AB, Canada

June 15-16 … Pittsburgh, PA

June 24-25 … Dallas, TX

July 9-10 … Edmonton, AB, Canada

July 14-15 … Adelaide, Australia

August 6-7 … Salt Lake City, UT

Our upcoming 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training will be held at the following locations on the following dates:

July 13-17 … Houston, TX

July 27-31 … St. John’s, NF, Canada

August 3-7 … Vancouver, BC, Canada

August 10-14 … Bogota, Colombia

August 17-21 … Knoxville, TN

Or you can have a course at your site. CONTACT US for a quote.

Whatever you do … Don’t miss these highly-rated courses! You need the best root cause analysis toolkit to improve performance at your facility.

Categories
Courses & Training, Investigations, Root Cause Analysis, Root Cause Analysis Tips
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