November 12, 2014 | Mark Paradies

Root Cause Analysis Tip: Top 10 Investigation Mistakes (in 1994)

Gatlinburg Sunrise 1

At the first TapRooT® Summit in Gatlinburg, Tennessee, in 1994, attendees voted on the top investigation mistakes that they had observed. The list was published in the August 1994 Root Cause Network™ newsletter (© 1994). Here’s the top 10:

  1. Management revises the facts. (Or management says “You can’t say that.”)
  2. Assumptions become facts.
  3. Untrained team of investigators. (We assign good people/engineers to find causes.)
  4. Started investigation too late.
  5. Stopped investigation too soon.
  6. No systematic investigation process.
  7. Management can’t be the root cause.
  8. Supervisor performs investigation in their spare time.
  9. Fit the facts to the scenario. (Management tells the investigation team what to find.)
  10. Hidden agendas.

What do you think? Have things change much since 1994? If your management supports using TapRooT®, you should have eliminated these top 10 investigation mistakes.

What do you think is the biggest investigation mistake being made today? Is it on the list above? Leave your ideas as a comment.

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2 Replies to “Root Cause Analysis Tip: Top 10 Investigation Mistakes (in 1994)”

  • Tony knight says:

    All investigative tools suffer the same fate. Change the senior staff and so does the outcomes. That’s human nature, vested interests or perceived vested interests in the outcome.
    Thr suggested mistake is using internal people for the investigation. Therefore bias protectionism and limited interference would be removed, assuming the correct protections are in place for the Contractor.

    • Mark Paradies says:

      Thanks for your comment.

      I believe it may be the nature of companies with a blame oriented vision to be protective (cover-up) what happened. But with an improvement-oriented vision, you can use a systematic process like TapRooT® to find and then fix the real root causes of problems. See https://www.taproot.com/what-vision-for-root-cause-analysis-does-your-company-have/.

      If you can develop a learning organization with an improvement-oriented vision, root cause analysis can flourish and performance will improve. I think this works better than having outside investigators.

      If you have outside investigators and a blame vision, blame will still be the main outcome.

      Outside investigators may be needed to help with complex, controversial, or client complaint investigations to provide a different (or in the client investigation – independent) set of eyes.

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