October 9, 2019 | Mark Paradies

TapRooT® Root Cause Analysis – Changing the Way the World Solves Problems

TapRooT® Root Cause Analysis Mission

A new TapRooT® User asked me why we have the “tag line:”

Changing the Way the World Solves Problems

I thought …

“That’s our mission.”

But people new to using TapRooT® may not understand how we got started and what we have accomplished that makes us successful at our mission of changing the way the world solves problems.

Why Change the Way the World Solves Problems

Back in the 1980s, there were very few systematic tools to help people find the root causes of problems. This was especially true of problems involving human error. I had recently completed a Masters Degree in Nuclear Engineering with a specialization in human factors (a rather different masters degree program) and I was recruited to work for Du Pont in a new group that was targeting improvements in process safety (although we didn’t call it process safety back then).

We knew that we were looking at infrequently occurring accidents that almost always had one or more “human errors” as part of the incident. We also realized that any major accident was almost always preceded by minor incidents that could have lessons learned that could prevent major accidents.

However, people weren’t finding the root causes of minor (precursor) incidents. Instead, they would stop when they found a human error and assign one of three corrective actions:

  1. Training
  2. Discipline (start with counseling the operator to be more careful)
  3. Procedure (write one, or, if you have one already, make it longer)

Once we started doing real root cause analysis of human errors, we also found that many things that were blamed on equipment failure were also caused by human error. The investigators found that it was better to blame incidents on the equipment (no disciple required) than to blame the incident on a human error.

We also found that BLAME was a big problem. I won’t go into the details, but when you find the real causes of human errors, the need to blame people almost completely goes away.

So, I took the knowledge that I used and started building it into a systematic process.

In 1988, I received permission from Du Pont to start a consulting business on the side to help other companies improve their root cause analysis. We started developing the first commercial root cause analysis tool with an emphasis on finding the root causes of human error – the first version of TapRooT®.

Thus, the reason we started on our mission to change the way the world solves problems was that we wanted others to be able to solve human error related issues and improve:

  • Process safety
  • Reactor safety
  • Industrial (worker) safety
  • Equipment reliability
  • Process reliability
  • Quality
  • Financial performance

We didn’t know our mission would be worldwide, but we knew that everyone faced similar problems – people making mistakes.

First Clients

System Improvements first clients were:

  • Philadelphia Electric
  • The U.S. Nuclear Regulatory Commission
  • Chevron

By the time we were done implementing TapRooT® at Chevron’s refineries, we had started having clients outside the US. Our first international clients were in:

  • Mexico
  • Canada
  • UK
  • Thailand

By 1994, we decided we needed to create a place where people could benchmark performance improvement ideas and share root cause analysis best practices. None of the professional societies were doing this, so we started the first TapRooT® Summit (held in Gatlinburg, Tennessee). Thirty-five of our best users got together and the learning was so valuable, we decided to have a Summit every year.

By 1995, we were on our third revision to the TapRooT® Manual (a three-ring binder notebook) and had standardized our 2-Day and 5-Day TapRooT® Courses. We saw many companies implementing TapRooT® on a worldwide basis and we started planning to have an international base of instructors with the ability to support languages other than English.

When We Realized We Are Changing the Way the World Solves Problems

It was at the 1996 TapRooT® Summit that we realized we were making a difference around the world. We had clients from the USA, Camada, Mexico, Thailand, the UK, Singapore, Norway, and Australia. One of our international TapRooT® Users told me about the difference TapRooT® was making at their company. How investigations were no longer blame oriented and people were willingly participating. How they were finding the root causes of problems that they previously would have overlooked. How they had reduced their lost-time injuries and saved lives.

After the Summit, I returned to our offices in Knoxville, Tennessee, talked with our small staff. I told them how we were having an impact in faraway places. And that’s when it hit us. We were changing the way the world solves problems one company at a time. And we were making an impact around the world. By 1998, we made this our mission statement:

Since then, we’ve added many clients in countries around the world. Many of them attend our Global TapRooT® Summit (the next one is at the Horseshoe Bay Resort near Austin, Texas, on March 9-13, 2020) and share their success stories of

  • Saving lives
  • Improving quality
  • Stopping lost-time accidents
  • Improving process safety
  • Improving equipment reliability
  • Improving process reliability

Our most rewarding experiences is when we are teaching TapRooT® at a site and an employee stops us to explain how they had made a mistake and they thought they would be fired. Instead, they participated in a TapRooT® Investigation and they discovered WHY they had made the mistake and WHY anyone else could have made the same mistake. The team they worked with found the root causes of the incident and fixed them so that no one else would make that mistake. Future incidents would be prevented. That’s what changing the way the world solves problems is all about. Teaching people to find and fix root causes that they previously would have overlooked. Even better, they can do this consistently.

Improving the Way the World Solves Problems

We aren’t resting on our laurels. Since we first developed TapRooT®, we have been constantly striving to make it better. We use our experience, feedback from the classes we teach, feedback from our users, and feedback from the TapRooT® Advisory Board to find areas where we can improve our:

And we add new tools and training when we find a need.

That’s why we have started having TapRooT® Evidence Collection and Investigative Interviewing Techniques Webinars and will soon have a new book and course about Stopping Human Error. For more info on the TapRppT® Evidence Collection and Investigative Interviewing Techniques Webinar, see:

https://www.taproot.com/course/evidence-collection-investigative-interviews/

Time to Change the Way You Solve Problems?

If you are a TapRooT® User or if you haven’t tried TapRooT® yet, maybe NOW is the time to improve your root cause analysis.

TapRooT® USERS…

The 2020 Global TapRooT® Summit is coming up on March 9-13 at the Horseshoe Bay Resort near Austin, Texas. CLICK HERE for more information about the Keynote Speakers and Best Practice Sessions.

If you have NOT tried TapRooT®…

Now is the time to give it a try! Attend one of our upcoming public TapRooT® Courses. Here are some dates and locations in the remainder of 2020:

2-Day TapRooT® Root Cause Analysis Training
(the Essentials Course)

Bogota, Colombia, October 22-23

São Paulo, Brasil, November 6-7

Oklahoma City, Oklahoma, November 7-8

Singapore, November 14-15

Amsterdam, Netherlands, November 21-22

Las Vegas, Nevada, December 2-3

Nashville, Tennessee, December 5-6

Houston, Texas, December 12-13

5-Day TapRooT® Advanced Root Cause Analysis
Team Leader Training

Newcastle, Australia, November 11-15

Bogota, Colombia, November 18-22

Houston, Texas, November 18-22

Perth, Australia, November 25-29

Edmonton, Canada, December 2-6

Johannesburg, South Africa, December 2-6

For a complete list of upcoming public TapRooT® Courses, see:

https://www.taproot.com/store/Courses/

Changing the Way the World Solves Problems…

 

 

 

 

 

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Root Cause Analysis
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