June 30, 2020 | Mark Paradies

Improved Investigations and Enhanced Management Interest and Acceptance by Using TapRooT® Root Cause Analysis

Improved Investigations and Enhanced Management Interest and Acceptance by Using TapRooT® Root Cause Analysis

Submitted by James M. Dougherty
Manager of Safety
Greater Cleveland Regional Transit Authority

This success story was written in the past and is being updated to our most recent blog article format and is being reposted here. The example shows how TapRooT® Root Cause Analysis can help improve incident investigations and enhance management interest and participation in performance improvement. These lessons apply just as much today as ever.


We wanted to improve our incident investigations, root cause analysis, and corrective actions.


In 2002, we decided that to reduce accidents, prevent injuries, and ultimately save money, we needed to do a better job investigating accidents. We investigated various improvement options and decided to use the TapRooT® System for investigation and root cause analysis.

Several of our staff attended System Improvements’ 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training and, after the course, started using the TapRooT® Software for investigations of bus and rail accidents, employee safety incidents, and safety issues.


We immediately noticed improvements in our investigations.

The SnapCharT® Diagram drawn using the SnapCharT® Software helped us understand the circumstances surrounding an incident.

The Root Cause Tree® (part of the TapRooT® Software) helped us analyze the root causes to a much greater level of detail. This better analysis and the Corrective Action Helper® Module of the TapRooT® Software helped us develop more effective corrective actions.

An unexpected but very valuable side benefit of our efforts has been the effect the TapRooT® System has had on the interest of management in our investigations and their acceptance and support of the investigations’ corrective actions.

Management has a much better understanding of what happened when we use the SnapCharT® Technique to present the incident to them. The presentation of the Safeguards (found using Safeguards Analysis) helps them understand how many or how few things had to fail to cause the incident. Management has commented that they now see corrective actions that they believe will be much more effective than before we started using TapRooT® Root Cause Analysis.

Because management support to pay for and assign resources to implement corrective actions is so important (because without the implementation of corrective actions, your analysis effort is wasted) the new enhanced support by management may be the most important benefit that we have seen.

In summary, by using the TapRooT® System we have achieved our goal of improved investigations, root cause analysis, and corrective actions. Also, we achieved ani even more important benefit of enhanced management interest and acceptance of investigations and greater support for implementing corrective actions. This is helping us improve transit safety and operations and will lead to cost savings.

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