February 16, 2010 | Mark Paradies

Root Cause Analysis Tip: Reviewing a TapRooT® Investigation

Several people have asked me:

“What should management look at
when reviewing a TapRooT® Investigation?”

I thought…

“That’s a great question,
I should write something so that
everybody can read and comment about it.”

I thought that I would provide the guidance by breaking up the suggestions by the 7-Step TapRooT® Reactive Investigation Process that is detailed in Chapter 3 of the TapRooT® Book (Copyright 2009, used here by permission).

NOTE: If you don’t understand the terminology or reasons for the management actions below, it could be that you need more TapRooT® Training!


TapRooT® 7-Step Reactive Investigation Process


So let’s start with Step 1: Planning the Investigation – Getting Started.

Since we are just getting started, there is nothing for management to review. However, management does have several responsibilities.

a. Management needs to set criteria for what gets investigated. This should be documented in the site’s incident investigation procedure. Management should then make sure that all incidents are reported and investigated. Occasionally, management will identify an incident that doesn’t meet the criteria, but still, in their opinion, deserves a complete investigation and root cause analysis.

b. Management should make sure that their site is prepared for investigations. This includes having an investigation procedure, trained investigators, and investigation review process, and trained management. See the TapRooT® Book (Chapters 3 and 6 and Appendix A and C) for more information.

c. Management should ensure that evidence is preserved for the team.

d. Management should make sure they they have assigned an adequate investigative team to perform the investigation and that the team has all the resources and support that they need. Depending upon the seriousness of the investigation, the team may include independent facilitators or coaches to help the team and outside experts for technical guidance. Management should assign an independent (not from the organization involved in the incident) Team Leader for all but the most minor investigations. The Team Leader should be thoroughly trained (probably in the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course).

e. Management should agree to an initial investigation scope (although the team should have the freedom to enlarge the scope based on the facts discovered during the investigation).

STEPS 2 & 3

Next, come Steps 2 & 3. I include these together because the main aspect that management will be reviewing is the team’s SnapCharT® with the incident’s Causal Factors. Management should make sure that:

a. The team has a detailed, logical SnapCharT® that is based on the evidence (facts) about the incident. Each Event and Condition should have a factual bases and not be an assumption (unless the reason for not verifying the assumption is adequately explained).

b. The evidence cannot support alternative scenarios.

c. All facts (not just those that supported this sequence of events) were considered.

d. Each Event includes the “Who did what” or “What did what” to clearly indicate the action that occurred.

e. ALL Causal factors have been identified (including those that were a “catch” for an error). May want to consider the using Safeguard Analysis to check the completeness of the Causal Factors.

f. The Causal Factors are the big picture causes of the incident and are not root causes. (They meet the definition of a Causal Factor and are at the “most general” end of the “So What?” chain.)

g. All Causal Factors have the associated information about them grouped together under the Causal Factor.

h. Only job positions (not people’s names) are used on the SnapCharT®.

i. Emphasis adjective are not used on the SnapCharT® (just state the facts – quantified when possible).

j. The Causal factors are repeatable and sufficient to cause the Incident.

STEPS 4 & 5

Next come Steps 4 & 5 – finding the incident root and generic causes. For these two steps, management should ensure that:

a. The team took each Causal Factor though the Root Cause Tree®.

b. Each root cause has evidence to support the finding and that the evidence provides a “Yes” answer to one of the questions in the Root Cause Tree® Dictionary.

c. The evidence is on the team’s SnapCharT®.

c. Management System root causes were considered.

d. The team checked for previous similar incidents and previous ineffective corrective actions.

e. Generic causes were considered for each root cause that was discovered.

f. The scope of the problem (Extent of Condition) and the scope of the cause (Extent of Cause) was considered in analyzing the root causes’ generic causes.

g. There is evidence to support the finding of generic causes.

STEPS 6 & 7

The final management jobs in Steps 6 & 7 are to ensure that sufficient corrective actions are adopted and implemented to prevent recurrence of this incident and, if applicable, similar incidents. Therefore, management should ensure that:

a. Each root cause/generic cause has a corrective action.

b. The corrective action is SMARTER.

c. The investigation team considered the recommendations in the Corrective Action Helper® (check their recommendations against the Corrective Action Helper®).

d. For a significant incident’s root causes, Type 1-4 corrective actions are used (see below). Preference should be given to removing the hazard if possible, next removing the target, and then guarding the target.


(From the TapRooT® Book. Copyright 2008. Used by Permission.)

e. Any corrective action that includes a “re” should be questioned. (For example: retrain, remind, and re-emphasize.) “Re” corrective actions are just repeating actions that didn’t work in the past. Why do we expect them to work now? Also, note that if the corrective action is counseling an employee to remind them about rules or procedures, this is “re” corrective action and should not be used alone, but must be combined with other behavior change techniques.

f. Reject any corrective action that includes these words – Ensure, Assure, Insure, Make Sure – unless the team can explain how they will make sure that the change occurs (and this additional information should be included in the corrective action to make it specific).

g. Corrective actions that are studies be carefully evaluated to see why the study has to be delayed and can’t be completed before the investigation is concluded. (Examples of studies are: Investigate, Evaluate, Consider, Analyze.)

h. Any corrective actions that require behavior to change have considered what factors are causing current behavior and how these will be removed and what rewards/incentives and punishment will be clearly linked to the desired behavior to make it occur.

i. Training is not used as punishment or to embarrass an employee.

j. The scope of the problem (Extent of Condition) and the scope of the cause (Extent of Cause) were considered in developing corrective actions and are documented on the SnapCharT®.

k. The people responsible for implementing the corrective actions and the people impacted by the corrective actions agree that the corrective action will be effective.

l. Corrective action will be sufficient to eliminate significant risk or if additional Safeguards or process redesign need to be considered because the risk is so significant.

m. Corrective actions are assigned to the appropriate individual/organization for implementation.

n. The organization responsible for corrective actions has adequate resources to implement the corrective action by the assigned due date.

o. The corrective actions are tracked, and if significant enough, verified, and validated. Management should periodically be updated on corrective action status, especially overdue corrective actions.

p. Significant corrective actions are periodically checked (audited) to ensure their continued effectiveness.

q. Significant corrective actions that may impact other facilities are shared within a corporation.

r. Names of employees are not used in the report.

s. Emphasis adjective are not used in the report (just state the facts).

t. Pictures are used effectively to help explain what happened in the report and presentation.

u. Rewards are given for good investigations.

v. Evidence and reports are retained to meet any legal requirements.

Not every one of these “management must” items must be performed by a manager for each investigation. Management can set up systems , review teams, or review boards to help ensure the quality of investigations.

– – – –

Now for your comments … What do you think? Additions? Deletions? Modifications?

And how is your site doing to make sure the TapRooT® Process is being used correctly, efficiently, and effectively?

By the way, many of the points above originally were shared as best practices at the TapRooT® Summit. If you would like to keep up with the latest TapRooT® best practices, attend the 2010 TapRooT® Summit in San Antonio on October 27-29.

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