May 6, 2009 | Mark Paradies

Root Cause Analysis Tip: What’s Wrong with this Root Cause of the Swine Flu

Here’s a question that I will call a “Trick Question” with a seemingly good, but wrong answer.

1. Question: What is the root cause of the swine flu?

Answer: The Swine flu virus.

This type of answer is a typical when people apply unstructured systems like 5-Why’s and Cause-and-Effect.

But why is this the answer WRONG?

First, they are asking about a natural phenomenon.

Why wouldn’t “human beings” be just as good a root cause?

Maybe the answer should be human beings and the virus?

Maybe we should go back to the original creation of “man”? Why weren’t we made virus proof?

You can see where this sort of thinking leads.

In TapRooT®, we would start by looking at a single case – perhaps the first fatal case of swine flu.


In the TapRooT® Model of an accident (above, Copyright 2008, System Improvements, Inc., used by permission), we would have to identify the Hazard, the Target, and the Safeguards.

The Hazard is the Swine Flu Virus (a biological hazard).

The Target is the human.

The Safeguards are the things we can do to keep the Hazard from impacting the Target. Examples include:

  • flu shots
  • hand washing
  • anti-viral masks
  • staying away from sick people

Next, we would draw a SnapCharT® of the sequence of events of the first infection.

I don’t have any details about this case so I won’t try to draw a complete SnapCharT® here. Some of the things to consider in the chart would be:

  • How the virus was created.
  • How the virus was transmitted to the first person who died.
  • The treatment of the first person who died.
  • The cause of death.

Once we had the complete details on our SnapCharT®, I would recommend the Safeguards 5 Question Method of finding the fatality’s Causal Factors. The five questions are shown in the graphic below. (Copyright 2008, System Improvements, Inc., Used by permission.) ..


So, we would be looking on our SnapCharT® for errors that:

  • Allowed the virus to be created.
  • Allowed any of the Safeguards that were in place to keep the virus from the person to fail (for example, the person not washing their hands when they should have).
  • Allowed a Safeguard to be missing (for example, if a flu shot was available, but the person didn’t get it, why didn’t they get it).
  • Allowed the Target (the person) to get too close to the Hazard (the virus) (for example, people living in very close proximity to pigs).
  • Allowed the infection to become worse and cause a fatality (for example, the failure to use anti-viral medications to flight the flu).

We would analyze any applicable Causal Factors and find root causes using the Root Cause Tree®.

We could do this for several cases and we would start to see patterns (Generic Causes) that we could address through the public health system.

Thus, using TapRooT®, an investigator could find root causes that meet the TapRooT® definition of a root cause…

Root Cause:

The absence of best practices
or the failure to apply knowledge
that would have prevented the problem
(or significantly reduce the likelihood
or consequences of the problem)

And that’s why TapRooT® works better than unstructured tools like 5-Whys and Cause-and-Effect.

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