June 22, 2009 | Mark Paradies

Monday Accident & Lessons Learned: Accident Response Can Make Things Worse

Read this story about the finding of a recent audit report about the TVA ash spill in Tennessee:


In this cases, there was a “Causal Factors” after the “Incident” (circle) on the SnapCharT®.

These type of Causal Factors don’t “cause” the incident, they do “cause” the accident to have worse consequences.

If you would like to learn more about advanced root cause analysis and incident investigation techniques, here are three ideas to consider:

1. Attend a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. Pick from course in:

  • Niagara Falls, Canada (July 6-10)
  • Melbourne, Australia (July 6-10)
  • San Antonio, USA (July 13-17)
  • Perth, Australia (July 20-24)
  • Seattle, USA (July 27-31)
  • Newcastle, Australia (Aug 3-7)
  • Brisbane, Australia (Aug 3-7)
  • Hong Kong, China (August 31 – September 4)
  • Edmonton, Canada (September 7-11)

For complete course information, schedule of courses, and registration, see:


2. Already attended a TapRooT® Course but want to learn the latest improvements in the techniques? Attend the 2-Day TapRooT® Advanced Techniques Course that is being held on October 5-6 in Nashville, Tennessee. For more information and registration, see:


3. If you want to learn best practices from around-the-world, attend the Investigation and Root Cause Analysis Track at the TapRooT® Summit on October 7-9 in Nashville, Tennessee. In addition to the great Keynote Speakers, you will also attend the following Best Practices sessions:

  • Accident Analysis Presentations (Attack on the USS Stark, Crandall Canyon Mine, 230 Environmental Incidents)
  • Success Stories from the Field (common cause analysis of multiple aviation accident investigations and proactive use of Safeguard Analysis for manufacturing quality improvement)
  • DISCover How To Communicate After an Accident
  • The Good, The Bad, and The Ugly: Which Describes Your Investigations and Reports and What Can You Do To Improve?
  • TapRooT® User’s Best Practice Forum
  • How To Prove That Fatigue Was the Cause of an Incident
  • Advanced Ideas for Defining Causal Factors
  • Lessons from Tennessee OSHA Fatality Investigations

For more Summit information or to register, see:


Show Comments

Leave a Reply

Your email address will not be published. Required fields are marked *