October 3, 2018 | Mark Paradies

Wait for a BIG Incident to Learn – Is This a Best Practice?

It must be a best practice because so many major companies do it.

They wait until something really bad happens to learn.

Here are some examples:

  • A pharmaceutical company waits for an FDA warning letter to fix quality issues.
  • A refinery waits for a major fire and environmental release with the associated EPA and OSHA investigations (and fines) to learn to improve process safety.
  • A mine waits for a major accident and the follow up MSHA investigation to improve mine safety.
  • A construction company waits for a multi-fatality accident and OSHA inspection and fine to learn to improve worker safety.

Screen Shot 2018 08 08 at 1 11 43 PM

They could have learned to improve from prior precursor incidents. They could have learned to improve by conducting proactive audits with root cause analysis of issues. But they would rather wait for the bad headlines and crisis that comes with a major incident. Maybe that’s how they get motivated?

Seriously, why do they fail to learn from precursor incidents and audits? Many times it is because they use poor root cause analysis techniques and implement ineffective corrective actions.

What should tip them off that their root cause analysis techniques are inadequate?

First, you can’t depend on the advice of so-called “experts.” There are many root cause analysis “experts” out there that are teaching inadequate techniques.

So how can you tell? Simple … repeat incidents.

If problems you fix with your root cause analysis system happen again, you are doing something wrong.

For example, many companies have adopted so-called “simple” root cause analysis techniques because they believe that is all their employees can learn. These ineffective simple techniques don’t get the investigators to the real root causes of human errors. The corrective actions they develop are superficial (warnings and more training). What happens? Weeks, months, or sometimes years later … the incident happens again. If you are unlucky … the incident is worse when it repeats.

Many managers complain that they don’t have time to do major investigations of every minor incident. They are right. So, what should they do?

First, they have to be selective. They have to evaluate their minor incidents, and decide which ones could have been worse – could have been bigger accidents if an additional Safeguard or two had failed.

For those that could have been worse, they need to use a proven-effective root cause analysis system, like TapRooT®, to investigate their precursor incidents (minor incidents that could have been worse).

To make this even easier while still being effective, the people at System Improvements – the developers of TapRooT® Root Cause Analysis – have a book and course that teaches the simple way to effectively investigate precursor incidents. The book is:

Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents

And the course is:

2-Day TapRooT® Root Cause Analysis Training

Where can you attend these courses? All around the world. Here is the upcoming schedule with dates and locations:


Don’t wait. You don’t know when the next fatality or major regulatory issue will occur. You need effective investigations of precursor incidents. For example, nobody died in the incident in the video below. It could have been a multiple fatality. The question that remains is … DID THEY LEARN?


Courses & Training, Root Cause Analysis, Safety
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