Root Cause Analysis Blog


Root Cause Tip Warning: Do not define the impact level of your incident too low or too high

Posted: October 19th, 2017 in Investigations, Root Cause Analysis Tips


When defining the Incident during a TapRooT® Root Cause Analysis and its impact to the business (the scope of your investigation), I often hear this statement…

“If we focus on the delay of correcting the problem, then less importance will be placed on what caused the problem.”

Take the scenario of a fire pump failing to turn on during a fire response test. The team originally wanted to focus on the pump failure only. Not a bad idea however, the pump could not be repaired for 2 weeks because of a spare part shortage. I pushed the team to raise the scope and impact of the investigation to Automatic Fire Suppression System out of service for 14 days.

Now this elevation of the incident does not lessen the focus on the pump failure, it does the opposite. A system down for 2 weeks elevates the focus on the pump failure because of impact and also allows the team to analyze why we did not have access to spare pump in a timely manner.

A caution also must be mentioned in that elevating the impact of an incident too high can cause a regulating agency to get involved or/and additional resources to be spent when not required.

Which problem is worse? Elevating a problem too high or not high enough? Your thoughts?

What Does a Bad Day Look Like?

Posted: October 19th, 2017 in Accidents

Stretcher fails!

Technically Speaking – 6.3.0 Feature: Corrective Action Notifications

Posted: October 19th, 2017 in Software Updates, Technical Support, Technically Speaking

Here is a look at the new Corrective Action Notification feature found in the latest TapRooT® VI update.

Technically Speaking is a weekly series that highlights various aspects of the 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!

Pictures from this week’s 5 Day TapRooT® Advanced Team Leader Course in Dubai

Posted: October 19th, 2017 in Courses

Today marks the end of another successful course in Dubai.
Here are some pictures from this week:

If you were not able to join us this week, sorry about that! We had a large demand for the course with a very long waiting list and were not able to accommodate everyone.

We have increased capacity for the next course but I still expect it to fill up very early – it is NOT TOO EARLY to sign up! The next course in Dubai will be on March 18 – you can see the information and enroll HERE

How Many Industries and How Many Countries is Your Root Cause Analysis System Used In?

Posted: October 17th, 2017 in Courses, Performance Improvement, Pictures, Root Cause Analysis Tips, TapRooT


I was talking to someone in the medical industry recently and they asked: “How many people in the medical industry use TapRooT®?”

I gave them several examples of major healthcare systems that use TapRooT® (including perhaps the worlds largest) but I thought … They asked the WRONG question.

The true value of a root cause analysis system is really proven is how many different places it is being used SUCCESSFULLY.

Note that this is not the same as if the system is used in a particular industry. It must be used successfully. And if it is used successfully in many other industries and many countries, that proves even more that the system is useful and will probably be useful when applied at your company.

Where is TapRooT® Root Cause Analysis applied successfully?

All over the world. On every continent but Antartica (we’ve never done a course there yet).

In what kind of industries? Try these:

  • Oil & Gas Exploration & Production
  • Refining
  • Chemical Manufacturing
  • Healthcare (Hospitals)
  • Pharmaceutical Manufacturing
  • Nuclear Power / Nuclear Fuels
  • Utilities
  • Auto Manufacturing
  • Aggregates
  • Mining (Iron, Gold, Diamonds, Copper, Coal, …)
  • Aluminum
  • Aviation (airlines and helicopters)
  • Shipping
  • Cosmetics
  • Construction
  • Data Security
  • Nuclear Weapons
  • Research Laboratories
  • Mass Transit
  • Regulatory Agencies
  • Prisons
  • Pulp & Paper
  • Engineering
  • Food & Drinks
  • Alchohol
  • Security
  • Recycling
  • Aerospace Manufacturing
  • Space Exploration
  • Pipelines
  • Agricultural Commodities
  • Steel
  • Forestry
  • City Government
  • General Manufacturing
  • Telecommunications
  • Airport Management

And that’s only a partial list.

Where can you read about the successful application of TapRooT® in some of these industries? Try these Success Stories:

 You will see examples of companies that saved lives, save money, prevent injuries, improved service, made work more productive, and stopped the cycle of blame and punishment.

The reason that TapRooT® is used by industry leaders is that it works in such a wide variety of industries in such a wide variety of countries.

But don’t just believe the industry leaders. Attend one of our GUARANTEED courses. Guaranteed? That’s right. Here is our guarantee:

  • Attend the course. Go back to work, and use what you have learned to analyze accidents, incidents, near-misses, equipment failures, operating issues, 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.

It’s that simple. Try to find a money-back guarantee like that anywhere else. We are so sure of your success that we guarantee it.

Don’t wait. Register for one of our root cause analysis courses today. For a list of upcoming public courses, see:

Monday Accident & Lessons Learned: How to Stop a Pellet Plant Explosion

Posted: October 16th, 2017 in Accidents

“One single ounce of oxygen. That’s all it would have taken for an explosion to have occurred… ”

While the potential for explosion is common for this industry, new learnings and experiences are being shared so that the industry is safer.

Read How to Stop a Pellet Plant Explosion on Canadian Biomass Magazine

TapRooT® Around the World

Posted: October 13th, 2017 in Pictures, Training

We were busy in Lake Charles this week!  Thanks, Angie Comer, for this great class photo!

Friday Joke

Posted: October 13th, 2017 in Jokes

TapRooT® Around the World: Intralox

Posted: October 12th, 2017 in Courses, Pictures

TapRooT® Instructor, Steve Swarthout sent us this course photo from this onsite course this week. Thanks, Steve!

If you have ten or more people to train and are interested in finding out more information about scheduling an onsite course, contact us.

Technically Speaking – September Customer Satisfaction Survey Prize Winner

Posted: October 12th, 2017 in Software, Technical Support, Technically Speaking

Here at System Improvements, customer satisfaction is very important to us. We strive to ensure our customers’ questions are treated in a timely and efficient manner.

This is so important to us that it’s actually part of our Technical Support Mission Statement:

To provide timely, courteous and effective technical support to System Improvements staff and all TapRooT® customers, achieving customer satisfaction and process efficiency.

In order to ensure we are providing great service, we have implemented a new customer satisfaction rating system, where our customers can rate their experience with our Support Team. The feedback has been extremely valuable to us.

As a thank you to all our customers who take the time to fill out a Survey, all respondents are entered into a monthly drawing to win a TapRooT® polo shirt.
Everyone, congratulate Scott Bittner, Dover HSES Manager from Edgewell Personal Care as the winner for the month of September!

Why do people jump to conclusions?

Posted: October 10th, 2017 in Human Performance, Performance Improvement, Pictures, Root Cause Analysis Tips

I see examples of people jumping to conclusions all the time. Instead of taking the time to analyze a problem, they suggest their favorite corrective action.

Why do they do this? I think it is because thinking is so hard. As Henry Ford said:

“Thinking is the hardest work there is, which is probably the reason why so few engage in it.”

Did you know that when you think hard, your brain burns more calories? After a day of hard thinking you may feel physically exhausted.

Neuroscientific research at Cal Tech has shown that the more uncertainty there is in a problem (a cause and effect relationship), the more likely a person is to use “one-shot” learning (jumping to conclusions). This simplification saves us lots of work.

What’s the problem with jumping to conclusions?


And even more important than saving effort in the analysis is that if you jump to a conclusion, you get to recommend the corrective action that you wanted to implement all along. Skip all that hard work of proving what the cause was and the details of developing effective fixes. Just do what you wanted to do before the problem ever happened!

The next time you are tempted to jump to a conclusion … THINK!

Yes, real root cause analysis and developing effective fixes is harder than just implementing the fix that you have been wanting to try even before the accident, but getting to the root (or roots) of the problem and really improving performance is worth the hard work of thinking.

Monday Accident & Lessons Learned: Mid-flight engine explosion forces landing

Posted: October 9th, 2017 in Accidents

“We looked out the window and saw half of the engine was missing.”

A rare emergency in which machinery and other parts broke away from a plane at high velocity occurred on an Airbus A380 with 500 passengers bound for Los Angeles.

The U.S. manufacturer of the engine, Connecticut-based Engine Alliance, said it was investigating the failure.

Read the article on NBC News.

TapRooT® Around the World: Arab Potash

Posted: October 9th, 2017 in Courses, Pictures, TapRooT

TapRooT® instructor, Heidi Reed sent these class photos from 1300 feet below sea level! Looks like a great class!


TapRooT® Around the World

Posted: October 6th, 2017 in Courses

It’s a wrap! Dave Janney & I had a great week with this group at our Knoxville 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. It’s not too late to get in the picture.  Here are some upcoming 5-day courses:

October 16: Orlando, Florida

October 23: Bogota, Colombia (Spanish)

October 30: Reykjavik, Iceland

November 13: Brisbane, Australia

November 13: New Orleans

November 27: Johannesburg, South Africa

November 27: Monterrey, Mexico

November 27: Perth, Australia

December 4: Edmonton, AB

December 11: Houston Texas

Friday Joke: No need to take the blame…

Posted: October 6th, 2017 in Jokes

when you can share it!

Technically Speaking – Predictive Location and Currency

Posted: October 5th, 2017 in Software, Technical Support, Technically Speaking

With the latest release of TapRooT® VI comes new features. Two of those features are Predictive Location and Currency, both of which are custom field features.


Technically Speaking is a weekly series that highlights various aspects of the 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!

Using TapRooT® Proactively – Mapping Out the Process

Posted: October 5th, 2017 in Summit, Summit Videos, Video, Video Depot

Watch Dave Janney discuss how TapRooT® can be used to map out the process.

Interviewing & Evidence Collection Tip: Get More Out of Interviews

Posted: October 5th, 2017 in Investigations, Root Cause Analysis Tips

Where can you find a good portion of information to complete your SnapCharT®? Interviews! And how do we obtain interviews? People!

Why do we often forget that we are collecting information from human beings? Remember that an accident investigation may be a stressful event for everyone involved. There may be serious injuries and worries about the repercussions of participating in interviews or worries about whatever discipline the employer may impose in a blame culture.

Throughout the process, treat everyone with sensitivity:

  • Be ready for the interview.
  • Greet the interviewee by name, a firm handshake and a smile.
  • Break the ice by initiating a brief conversation not related to the incident. Put the interviewee at ease by listening to their contributions to the conversation without interruption.
  • Explain the interview process so they know what to expect.
  • Make it a practice to review the notes with the interviewee at the end of the interview. Let them know you will be doing that after explaining the process. They will feel more at ease if they have the opportunity to make any clarifications necessary.

Consideration for people’s fears goes a long way toward earning buy-in and confidence in the process.

What other things do you do to help an interviewee feel comfortable with the interview process? Share your ideas in the comments section below.

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