December 15, 2020 | Mark Paradies

Unknown Root Causes


What Do You Do When the Root Cause is Unknown?

I was reviewing an incident investigation report. It started with an equipment failure. But as I read along, I couldn’t understand what happened. To me, it seemed like the root causes were unknown.

The incident report didn’t have a SnapCharT®, so I used the information in the report to draw one. I couldn’t draw the sequence of events (as described in the report). One thing did not lead to the next. Information was missing. Some “facts” contradicted other “facts.”

I decided to call the investigator to clear up the contradictions and missing info. We had an interesting conversation. He tried to explain things but he couldn’t. Finally, he said:

“Ok, I’ll admit it. I really couldn’t figure out how this happened
but I had to write a report and recommend corrective actions
and this was the best I could do.”

I suggested that I could help him understand what happened if he wanted to get to the bottom of the problem. He agreed and we spent an afternoon reviewing what he had done and visiting the site of the incident.

The new information we found after visiting the site and talking to workers helped us complete a SnapCharT® that made sense.

What did we find? It wasn’t really an equipment failure. The incident started because of a human error caused by bad human factors design of an equipment interface. That led to the failure of the equipment.

The additional investigation and complete SnapCharT® helped us discover a human factors issue. If we didn’t discover and fix the human factors issue, the incident probably would have happened again. (It had happened in the past and wasn’t fixed by previous investigations.)

What Causes Unknown Root Causes?

Why did the investigator (and previous investigators) fail to find the human factors cause of the failure? Because they never had any human factors training. They were smart people and had good engineering knowledge, but they had never been trained in why humans make mistakes – the science of human factors.

Thus, they couldn’t understand the cause, or even what to look for, because the root cause was unknown to them.

How can you solve the problem of unknown root causes at your facility? You could train all your investigators to be human factors experts. This would take a couple of years and lots of time in the classroom and the field.

What is a better alternative? Train your investigators to use TapRooT® Root Cause Analysis. TapRooT® RCA has a built-in expert system to help investigators find the causes of human errors (part of the Root Cause Tree®). And your investigators will learn to use the SnapCharT® Diagram to understand what happened. The combination of SnapCharT® and the Root Cause Tree® will make your investigators much more effective in finding the causes of incidents they previously didn’t understand (unknown root causes).

Root Cause Tree®

But that’s just two of the advantages TapRooT® RCA provides. There’s more.

Part of finding an incident’s root causes is identifying all the incident’s Causal Factors. TapRooT® RCA has the new Causal Factor Worksheets to help your investigators identify ALL the Causal Factors.

Causal Factor Worksheet

Also, once the root causes (both specific and generic) have been identified, TapRooT® RCA includes the Corrective Action Helper® Guide/Module to help investigators recommend more effective corrective actions.

Would you like to learn more about TapRooT® Root Cause Analysis to help your investigators effectively find the cause of unknown root causes? Here are some ways to learn more…

Mark Paradies and Kathy Ireland Discuss TapRooT® RCA

First, you can watch this video of Mark Paradies being interviewed by Kathy Ireland…

TapRooT® Training

Second, and probably the best way to learn more is to attend TapRooT® Root Cause Analysis Training. You can pick from our 2-Day or 5-Day Courses.

2-Day TapRooT® Root Cause Analysis Training

The 2-Day TapRooT® Root Cause Analysis Course focuses on the essential TapRooT® Techniques needed to investigate a precursor incident. The 5-Step investigation process simplifies TapRooT® to make the investigation efficient yet effective. The training focuses on understanding what happened, identifying Causal Factors, analyzing the Causal Factors using the Root Cause Tree®, and developing effective fixes using the Corrective Action Helper® Guide.

For more information CLICK HERE. To see the upcoming public course schedule, CLICK HERE.

2-Day Equifactor® Equipment Troubleshooting and TapRooT® Root Cause Analysis Training

Do you need to efficiently and effectively find the root causes of equipment failures to improve your facility’s equipment reliability? Imagine the downtime prevented and money saved NOT having repeat equipment failures. If this sounds interesting (and worthwhile), then this completely revised course is for you.

The Equifactor® Techniques are based on the work of noted equipment reliability expert Heinz Bloch.

In two days, you will learn how to use Equifactor® to troubleshoot equipment issues and find out what is leading to failures. Then you will learn to use the TapRooT® System to organize the information you collect, identify the Causal Factors of the failure, and find the fixable root causes of the failure. Finally, you will learn to develop effective fixes to stop future equipment failures.

For more information about the 2-Day Equicator®/TapRooT® Training, CLICK HERE. To see our upcoming public course schedule, CLICK HERE.

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

The 5-Day Training is for people who investigate precursor incidents and, perhaps, major incidents (serious injuries, fatalities, major facility upsets, fires, and explosions, or significant environmental releases). The course covers the essential TapRooT® Techniques (SnapCharT®, Safeguards Analysis, the Root Cause Tree®, and the Corrective Action Helper®), and the optional tools (Change Analysis, CHAP, and Equifactor®) that are used in a complex investigation. In addition, the course covers advanced interviewing and information collection techniques and techniques to improve human performance. There are frequent exercises using the TapRooT® Software so that attendees leave with significant practice of the skills they will apply when they get back to work.

For more information about the 5-Day Training, CLICK HERE. For the upcoming public course dates and location, CLICK HERE.

Root Cause Analysis White Paper

Third, you can request a white paper that explains more about TapRooT® Root Cause Analysis. Just fill out the simple form below.

Don’t Wait

Whatever you do, don’t wait. You want to stop unknown root causes and start fixing the real root causes before these problems lead to more significant accidents.

Ken Reed Teaching
Courses & Training, Equipment Reliability / Equifactor®, Human Performance, Investigations, Root Cause Analysis Tips
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