Root Cause Analysis Blog


TapRooT® Around the World

Posted: March 16th, 2018 in Courses, Pictures, TapRooT

TapRooT® instructor, Marco Flores-Verdugo, sent us these photos from a course in Monterrey, Mexico that Marco and Jesus Reynoso taught. Looks like a fun group, and they had a good time learning how to us TapRooT®.

Want to attend a TapRooT® training course? Check out our upcoming course near you. All you need to do is click here.

Miami Bridge Collapse – Is Blame Part of Your Investigation Policy?

Posted: March 16th, 2018 in Accidents, Investigations

collapse miami bridge








I was listening to a news report on the radio this morning about the pedestrian bridge collapse in Miami. At one point, they were interviewing Florida Governor Rick Scott.  Here is what he said:

“There will clearly be an investigation to find out exactly what happened and why this happened…”

My ears perked up, and I thought, “That sounds like a good start to a root cause investigation!”

And then he continued:

“… and we will hold anybody accountable if anybody has done anything wrong,”

Bummer.  His statement had started out so good, and then went directly to blame in the same breath.  He had just arrived on the scene.  Before we had a good feel for what the actual circumstances were, we are assuming our corrective actions are going to pinpoint blame and dish out the required discipline.

This is pretty standard for government and public figures, so I wasn’t too surprised.  However, it got me thinking about our own investigations at our companies.  Do we start out our investigations with the same expectations?  Do we begin with the good intentions of understanding what happened and finding true root causes, but then have this expectation that we need to find someone to blame?

We as companies owe it to ourselves and our employees to do solid, unbiased incident investigations.  Once we get to reliable root causes, our next step should be to put fixes in place that answer the question, “How do we prevent these root causes from occurring in the future?  Will these corrective actions be effective in preventing the mistakes from happening again?”  In my experience, firing the employee / supervisor / official in charge rarely leads to changes that will prevent the tragedy from happening again.


Friday joke

Posted: March 16th, 2018 in Jokes

ASSE Safety 2018 Flash Session on Investigative Interviewing

Posted: March 15th, 2018 in Investigations, Media Room

I’m excited to be selected as a flash session speaker for ASSE Safety 2018. My talk “Top 3 Tips for Improving your Investigative Interviewing Skills” is planned for Monday, June 4, 2018 at 2:45 p.m. in the Exhibit Hall, Booth #2165. I hope to see you there! Please stop by the TapRooT® Booth and talk to Dave Janney and me while you’re at the conference.

Technically Speaking – February Customer Satisfaction Survey Prize Winner

Posted: March 15th, 2018 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 Gabe Aron from Exelon as the winner for the month of February!

Root Cause Tip: Luck Versus Being Consistent, Success and Failure Can Come From Both

Posted: March 14th, 2018 in Accidents, Courses, investigation, Performance Improvement, Quality, Root Cause Analysis Tips, Root Causes, TapRooT, Wisdom Quote

Every best practice can be a strength or a weakness. Even one phrase like “I will ____” can be self-defeating or uplifting. “I will succeed” versus “I will fail.” Both phrases set your compass for success or failure. Okay, so what does philosophy have to do with root cause analysis? Simple….

Practice safe behaviors, build and sustain safe and sustainable processes with good best practices, and success is measured by less injuries, less near-misses, and more efficient processes.

Practice unsafe behaviors, build unsafe but sustainable processes with poor best practices, and success is measured by more injuries, more near-misses, and wasteful business processes. Safety only happens by luck!

Guess what? In many cases, you can still be in compliance during audits but still meet the criteria of “unsafe but sustainable processes with poor best practices . . . measured by more injuries, more near-misses, and wasteful business processes.”

This is why Question Number 14 on the TapRooT® Root Cause Tree® is so important.

Not every Causal Factor/Significant Issue that occurred during an incident or was found during an audit is due to a person just breaking a rule or taking shortcuts. In many cases, the employee was following the rules to the “T” when the action that the employee performed, got him/her hurt or got someone else hurt.

Take time to use the TapRooT® Root Cause Tree®, Root Cause Tree® Dictionary, and Corrective Action Helper® as designed to perform consistently with a successful purpose.

Want to learn more? Attend one of our public TapRooT® Courses or contact us to schedule an onsite course.

Watch Facebook Live on Wednesdays: Next up is Body Language

Posted: March 13th, 2018 in Career Development, TapRooT

Be sure to catch TapRooT®’s Facebook Live session on Wednesday, March 14, 2018. TapRooT® Instructor and Nonverbal Communication Expert Barb Phillips and Implementation Strategist Benna Dortch will discuss, among other topics, how to interpret common body language cues.


When? Wednesday, March 14

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Another recent FB Live sessions features Benna Boring and Ken Reed discussing the top six takeaways attendees said they wanted to incorporate into their companies after attending the 2018 Global TapRooT® Summit. We can’t wait for March 11-15, 2019, for our next Summit near Houston, Texas! Mark your calendars and begin making plans now!

Testimonial Tuesday

Posted: March 13th, 2018 in Uncategorized

If you have attend one of courses or a TapRooT® Summit at some point you’ve probably been asked to give a testimonial or filled out one of our course evaluations. We here at System Improvements take your testimonials and evaluations seriously. So, thank you for your statements that continue to help us grow and improve.

See what people have to say about our new Corrective Action Helper®.

  • “The book Corrective Action Helper® is a very good quick line for C.A. in general.” – W. Wiech
  • “The Corrective Action Helper® guide will certainly prove valuable.” – Terry Fisher

Read what benefits people received from attending our 2-Day Training Course.

  • “Gives you the ability to remove bias out.” – Jackie Nippard
  • “I see myself improving on the entire II process and I now have the tools to improve.” – Mark
  • “I have a better perspective of the details that contribute to incidents.” – Waylon Munch

Hire a Professional

Posted: March 12th, 2018 in Accidents, Career Development Tips, Performance Improvement, Training

root cause analysis, RCA, investigation










I know every company is trying to do the best they can with the resources that are available. We ask a lot of our employees and managers, trying to be as efficient as we can.
However, sometimes we need to recognize when we need additional expertise to solve a particular problem. Or, alternatively, we need to ensure that our people have the tools they need to properly perform their job functions.  Companies do this for many job descriptions:

  • Oil analyst
  • Design engineer
  • Nurse
  • Aircraft Mechanic

I don’t think we would ask our Safety Manager to repair a jet engine.  THAT would be silly!

However, for some reason, many companies think that it is OK to ask their aircraft mechanics to perform a root cause analysis without giving them any additional training.  “Looks like we had a problem with that 737 yesterday.  Joe, go investigate that and let me know what you find.”  Why would we expect Joe, who is an excellent mechanic, to be able to perform a professional root cause analysis without being properly trained?  Would we send our Safety Manager out to repair a jet engine?

It might be tempting to assume that performing an RCA is “easy,” and therefore does not require professional training.  This is somewhat true.  It is easy to perform bad RCA’s without professional training.  While performing effective  investigations does not require years of training, there is a certain minimum competency you should expect from your team, and it is not fair to them to throw them into a situation which they are not trained to handle.

Ensure you are giving your team the support they need by giving them the training required to perform excellent investigations.  A 2-Day TapRooT® Essential Techniques Course is probably all your people will need to perform investigations with terrific results.


Amplify Your Presentations by Adapting to Your Audiences

Posted: March 12th, 2018 in Career Development

The following article is reprinted with permission of its author, Vincent Ivan Phipps, M.A., CSP. We want to thank Mr. Phipps for being a keynote speaker at our 2018 Global TapRooT® Summit.  You can purchase his new book, Lead Out Loud, and learn how to unlock your personal excellence by clicking here. Learn more at

Your best marketing plan is your ability to effectively speak. If you are comfortable talking or if you have to muster the courage to speak in front of strangers, adapt you messages to the four types of audiences that are feature in the book, Lead Out Loud! – Keys to Unlock Professional Excellence!.

This type of audience wants short and direct information. Avoid giving too many details and make sure to succinctly cover your main points early and often.

This type of audience needs step by step information. Allocate time for questions and be sure to provide reassurance. Avoid selling too soon before establishing trust.

This type of audience loves humor, engagement and good stories. Hit the high points and name drop. Avoid going into processes and focus on the people

This type of audiences needs data. Be sure to give reference material and cite you sources. Do your research before sharing content to ensure accuracy. Avoid using ambiguous terms and speak with validity.

Adapt to your audience and see your presentation results amplify!

– Vincent Ivan Phipps, M.A., CSP
Certified Speaking Professional, Author and Owner of Communication VIP Training and Coaching





Monday Accidents & Lessons Learned: When a disruption potentially saves lives

Posted: March 12th, 2018 in Accidents

Early news of an incident often does not convey the complexity behind the incident. Granted, many facts are not initially available. On Tuesday, January 24, 2017, a Network Rail freight train derailed in south-east London between Lewisham and Hither Green just before 6:00 am, with the rear two wagons of the one-kilometer-long train off the tracks. Soon after, the Southeastern network sent a tweet to report the accident, alerting passengers that, “All services through the area will be disrupted, with some services suspended.” Then came the advice, “Disruption is expected to last all day. Please make sure you check before travelling.” While Southeastern passengers were venting their frustrations on Twitter, a team of engineers was at the site by 6:15 am, according to Network Rail. At the scene, the engineers observed that no passengers were aboard and that no one was injured. They also noted a damaged track and the spillage of a payload of sand.

The newly laid track at Courthill Loop South Junction was constructed of separate panels of switch and crossing track, with most of the panels arriving to the site preassembled. Bearer ties, or mechanical connectors, joined the rail supports. The February 2018 report from the Rail Accident Investigation Branch (RAIB), including five recommendations, noted that follow-up engineering work took place the weekend after the new track was laid, and the derailment occurred the next day. Further inspection found the incident to be caused by a significant track twist and other contributing factors. Repair disrupted commuters for days as round-the-clock engineers accomplished a complete rebuild of a 50-meter railway stretch and employed cranes to lift the overturned wagons. Now factor in time, business, resources saved—in addition to lives that are often spared—when TapRooT® advanced root cause analysis is used to proactively reach solutions.

Equifactor and FMEA

Posted: March 12th, 2018 in Equipment/Equifactor®

equifactor, repair, FMEA









For those of you that have met me, you know that I am a huge fan of proactive improvement processes. Why wait until something bad happens to fix your issues? Wouldn’t it be nice if we could fix problems before we have an incident that actually hurts someone, or damages our equipment?  I’ve spoken numerous times about using TapRooT® proactively for HSEQ problems, but I wanted to give you a tool to help you with your proactive equipment troubleshooting.

Design and process engineers are usually familiar with Failure Modes and Effects Analysis, or FMEA.  This is a generic tool that can be used to look at a piece of equipment or a process, identify what can go wrong, and determine more stringent controls should be put in place to prevent that failure.  There are actually quite a few ways to do this, but most FMEA’s are all based on a fairly standard format.  For this discussion, I’m going to focus on equipment failures.  Generally, the system walks you through several distinct steps:

  1. Identify the piece of equipment you wish to analyze.
  2. Look at all realistic potential failure modes that can occur with that equipment.
  3. Assign a Severity, Occurrence, and Detectability score to each failure
  4. Multiply these scores together to calculate a Risk Priority Number (RPN).
  5. Determine the controls that are currently in place to prevent this issue.
  6. Decide if additional controls are required, based on the RPN.

Now, looking at these steps, it occurs to me that many of these steps are somewhat subjective.  For example on a scale of 1-10, what is the Severity of the failure?  Most companies have put a matrix in place to help quantify these numbers and make it easier to come up with consistent results.  This guidance is really important if you want to have any kind of meaningful, systematic way of determining that RPN.  While not perfect, these matrices do a pretty good job of keeping everyone focused and getting consistent answers.

However, the one step that is still VERY subjective is step #2.  Somehow, you need to come up with a list of all the potential failure modes that your piece of equipment can experience.  This is the very basis of the entire analysis, and it is probably the most difficult.  Imagine telling your maintenance manager or design engineer, “Tell me all the ways this compressor can fail.”  While I’m sure your team is pretty sharp, this is a daunting task.  Ideally, they will need to list every possible failure mode to ensure we don’t miss anything.  Imagine how many “unknown unknowns” are floating around in our FMEA’s!

Wouldn’t it be nice if there were some compendium of possible failures that we could use to initially populate our FMEA list?  This is where I would recommend pulling up your Equifactor® tables.  Take a look at (for example) the Centrifugal Compressor troubleshooting tables.  Just in this category alone, we have nearly 50 possible failure modes, spread across 7 symptoms.  Imagine if you could start your FMEA with all of these items.  You’d be well on your way to conducting a detailed FMEA on your centrifugal compressors, with the ability to add a few more failure modes that may be unique to your situation.

We normally think about Equifactor® as a reactive troubleshooting tool.  While it excels in that mode, try using the Equifactor® tables more proactively.  Use those tables as the baseline for your FMEA, and limit the number of unknown issues that may be lurking in your equipment.


Career Opportunities for Candidates with TapRooT® Skills

Posted: March 12th, 2018 in Career Development, Job Postings

Let your expertise speak for itself. Professional training and skill sets in investigation, problem-solving, and root cause analysis will telegraph competency to the potential employer across the desk from you. If you have TapRooT® training and skills, step up into a new career through one of these global opportunities.

Chemical Laboratories and Corporate Office

QHSSE Advisor

Manager, Safety & Health

EHS Manager II

Service Delivery Coordinator

HSE Site Supervisor

Being TapRooT® trained in troubleshooting and identifying root causes of issues and incidents is the proven path to develop your skill sets and training. Pursue your goals through TapRooT® courses to advance your professional development.

Dubai, UAE, March 18, 2018, 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Charlotte, NC, March 19, 2018, 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Bogota, Colombia, March 21, 2018, 3-Day TapRooT® Equifactor®

Brisbane, Australia, April 16, 2018, 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Las Vegas, NV, April 23, 2018, 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

TapRooT® Around the World

Posted: March 9th, 2018 in Courses, TapRooT

TapRooT® instructor, Heidi Reed, sent us these photos from a course that she and Barry Baumgardner are teaching at Energy XXI in Grand Isle, LA. Looks like a great group!


Want to learn about your onsite course options?

Contact us!

2018 TapRooT® Global Summit Twitter Highlights

Posted: March 9th, 2018 in Pictures, Summit

First, I would like to start off by thanking everyone who attended the Summit this year. It was a great success, and we here at System Improvements received lots of positive feedback from everybody. Without our amazing clients, instructors, and employees we wouldn’t be here today so thank you! Because of you, we get to be in the business of saving peoples lives.

Okay, I am finished with the mushy stuff… Let us get on with the fun photos!

The Twitter Contest was a huge success. We received tons of photos, quotes, and videos. So many in fact there is no way I could include every tweet. If I did the post would be 5,000 pages long!

Below are just a few of my favorite tweets I saw through out the week. If you would like me to generate more posts with more of my favorite tweets please leave it in a comment below, or email me at


Friday joke

Posted: March 9th, 2018 in Jokes

Caption Contest!

Posted: March 8th, 2018 in Contest, Pictures

Now that the summit is over we can begin a new caption contest! I’m sure when your boss says, “Get the job done safely…” This is exactly what he had in mind. Make sure to read and follow the instructions below so you can qualify to win.

How would you caption the above photo? Put on your creative hat and read the contest instructions below. Enter as many times as you want, and if you’ve won our contest before, you are still eligible to enter this one!

Contest Instructions:
1. Create your caption to the photo above in five words or less. All captions with more than five words will be disqualified.
2. Type your caption in the comments section of this post by April 2, 2018.
3. If you haven’t already, subscribe to the Tuesday TapRooT® Friends & Experts e-newsletter. You must be a subscriber to win!

Have fun!

Keeping Your Equipment Reliability Team Sharp

Posted: March 7th, 2018 in Career Development, Equipment/Equifactor®, Summit

study, read, reliability, troubleshoot








We have just completed our annual Global TapRooT® Summit, and we all walked away with some terrific ideas to bring back to our companies. Many people think the Summit is only for our customers to improve their processes, but I ALWAYS come away with new ideas for myself.

Heinz Bloch was one of our speakers this year.  He had 2 excellent sessions on how equipment reliability is tied directly to your company’s bottom line.  As always, he had some great insights into how a company can integrate reliability techniques into their business model for real, measurable savings.

One of his observations is that, as technology progresses, it is imperative that your reliability and maintenance team  keep up-to-date on the current best practices and technologies.  It is too easy to assume your excellent reliability and maintenance engineers will just magically remain top-notch.  His suggestion (almost a demand!) was to ensure we give our team the time and motivation to actually READ about their craft.  Your team should be allocating some amount of time EVERY DAY to reading professional journals and articles to see what is happening outside their own company boundaries.

  • Are you using the very best lubricant?
  • What new bearing materials are available for your applications?
  • How much can we save by investing in slightly more expensive, but much more efficient technology?
  • What are our competitors using for condition-based maintenance?

As managers, we should be giving our team both the time and the incentive to read these journals and articles.  Trust me, your competition is doing this; don’t be left behind!

What does bad root cause analysis cost?

Posted: March 7th, 2018 in Accidents, Performance Improvement, Pictures, Root Cause Analysis Tips, Training


Have you ever thought about this question?

An obvious answer is $$$BILLIONS.

Let’s look at one example.

The BP Texas City refinery explosion was extensively investigated and the root cause analysis of BP was found to be wanting. But BP didn’t learn. They didn’t implement advanced root cause analysis and apply it across all their business units. They didn’t learn from smaller incidents in the offshore exploration organization. They didn’t prevent the BP Deepwater Horizon accident. What did the Deepwater Horizon accident cost BP? The last estimate I saw was $22 billion. The costs have probably grown since then.

I would argue that ALL major accidents are at least partially caused by bad root cause analysis and not learning from past experience.

EVERY industrial fatality could be prevented if we learned from smaller precursor incidents.

EVERY hospital sentinel event could be prevented (and that’s estimated at 200,000 fatalities per year in the US alone) if hospitals applied advanced root cause analysis and learned from patient safety incidents.

Why don’t companies and managers do better root cause analysis and develop effective fixes? A false sense of saving time and effort. They don’t want to invest in improvement until something really bad happens. They kid themselves that really bad things won’t happen because they haven’t happened yet. They can’t see that investing in the best root cause analysis training is something that leads to excellent performance and saving money.

Yet that is what we’ve proven time and again when clients have adopted advanced root cause analysis and paid attention to their performance improvement efforts.

The cost of the best root cause analysis training and performance improvement efforts are a drop in the bucket compared to any major accident. They are even cheap compared to repeat minor and medium risk incidents.

I’m not promising something for nothing. Excellent performance isn’t free. It takes work to learn from incidents, implement effective fixes, and stop major accidents. Then, when you stop having major accidents, you can be lulled into a false sense of security that causes you to cut back your efforts to achieve excellence.

If you want to learn advanced root cause analysis with a guaranteed training, attend of our upcoming public TapRooT® Root Cause Analysis Training courses.

Here is the course 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/software
and we will refund the entire course fee.

Don’t be “penny wise and pound foolish.” Learn about advanced root cause analysis and apply it to save lives, prevent environmental damage, improve equipment reliability, and achieve operating excellence.

TapRooT® on Worldwide Business with Kathy Ireland®

Posted: March 6th, 2018 in Uncategorized

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®.

Protection Against Hydrogen Sulfide

Posted: March 6th, 2018 in Accidents, Investigations

On January 16, 2017, a private construction company sent four utility works to handle complaints about sewage backup in Key Largo, Florida. Three of the four works descended into the the 15-foot-deep drainage hole, and within seconds all voice communication was lost amongst the construction workers.

The Key Largo Fire Department was the first to respond to the scene. Leonardo Moreno, a volunteer firefighter, tried to enter the hole with his air tank but failed. So, he descended without his air tank and lost consciousness within seconds of entering the drainage hole. Eventually, another firefighter was able to enter the hole with an air tank and pull Moreno out. Unfortunately, the other three construction workers weren’t so lucky. All of them died from hydrogen sulfide poisoning, and Moreno was in critical condition.

Unfortunate events like this are completely avoidable. Comment below how this could have been avoided/prevented by using TapRooT® proactively.

To learn more about this tragic incident click here.

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Hands-on learning is so important when learning something new. We keep this in mind when developing root cause analysis training and our course attendees appreciate it too. Here’s some feedback we’ve received lately: “Great hands on exercise [for developing Corrective Actions] and great class involvement.” ~ D. Rind “Very good to get a feel of …

TapRooT® is a key part of our safety improvement program that has helped us stop injuries and save lives.

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