February 12, 2020 | Mark Paradies

What Does Senior Management Need to Know About Root Cause Analysis to Keep Your Company Out of Trouble?

Root Cause Knowledge for Senior Managers

What does a Plant Manager, a Vice President, or a COO need to know about root cause analysis to be an effective leader? Quite a lot because learning from experience to achieve world-class performance should be part of their set of tools for creating a truly effective company.

The opposite way to look at it is that you would NOT want a senior manager who:

  • Could not recognize a root cause.
  • Thought that 5-Whys was an effective problem-solving tool.
  • Reacted with knee-jerk reactions whenever something went wrong.
  • Punished people for system caused errors.
  • Used “gut feel” instead of performance data to steer the company.

What are the basics that they should be familiar with? Read on and find out.

How to Perform an Advanced Root Cause Analysis

Really, managers should have learned this as a basic part of their management training. But advanced root cause analysis isn’t part of an MBA program. And many companies still think that 5-Whys is an OK root cause tool. Therefore, many managers don’t learn advanced root cause analysis (TapRooT®).

What problems does this lack of knowledge cause?

First, they don’t know what a proper root cause analysis looks like. Therefore, they will accept substandard root cause analysis and problems won’t be effectively fixed.

You might think this poor root cause analysis would be immediately apparent because incidents would repeat. But senior managers only get presentations about the worst accidents. And the worst accidents are rare. Therefore, they don’t repeat frequently. Thus, managers don’t get feedback about the poor root cause analysis. Instead, they see each accident as a completely new set of failures.

When substandard root cause analysis is allowed, smaller problems don’t get fixed until major accidents happen. Instead of seeing the major accidents as a failure of previous root cause analysis, senior management sees the major accidents as an anomaly or after the major accidents, senior management gets fired. In either case, the root cause analysis system remains weak.

What senior management should be asking is why the major accidents weren’t prevented by investigations of precursor incidents. Of course, the answer to this question is that the precursor incidents weren’t investigated well. They didn’t get a thorough root cause analysis with an effective system like TapRooT® that would recommend effective fixes.

But would it be OK if they just would let people use TapRooT® Root Cause Analysis that they didn’t understand? No.

Why? because sooner or later they would be transferred somewhere and decide that a technique they heard about (like Lean) was the next greatest thing. And that tool uses … Fishbone Diagrams. So, they need to get their folks to use Fishbone Diagrams. And their root cause analysis would gradually go downhill as the TapRooT® Users moved along and their investigations gradually became worse with less effective fixes.

If you don’t understand this process of slipping back into ineffective root cause analysis, it could be that you don’t know what advanced root cause analysis does for you.

How to Review and Approve a Root Cause Analysis

Bad Meeting

Senior managers seldom perform a root cause analysis. They will frequently review root cause analyses performed by others, often either approving them or approving the resources needed to implement corrective actions.

What is the difference between performing a root cause analysis and approving one?

Think of it as the difference between being an artist and an art critic.

To perform a good review, you need to ask the right questions to see if the investigator asked the right questions, thoroughly understood what happened, identified all the Causal Factors, found their root causes and Generic Causes, and developed effective fixes.

The development of corrective actions is often an exercise in risk management. Were weak or strong corrective actions (Safeguards) used? Could (or should) the Hazard or Target have been removed? How much residual risk is management willing to live with? Is the selection of corrective actions a conservative management decision?

Often, investigators will try to please senior management by developing the cheapest fixes possible. But senior management may want to remove certain risks that are a threat to the company’s franchise or to their continued employment. Sometimes it is wise for management to choose the more expensive, thorough corrective actions that eliminate the risk of a similar future accident rather than just applying a band-aid. (The former CEO of Boeing may see the wisdom in this after the fiasco involving the 737 Max).

Thus, senior management must not only understand root cause analysis but also the big picture of risk management when approving corrective actions.

How to Trend Root Cause Analysis Data

Senior managers should understand that just like financial data, safety and quality data should be used to manage the company. But many (if not most) senior managers don’t understand the advanced trending techniques needed to analyze infrequently occurring safety statistics. These statistics can’t be analyzed like financial statistics. They need to be analyzed using time-between process behavior charts and instantaneous rate process behavior charts (see the book, Performance Measures and Trending for Safety, Quality, and Business Management, and CLICK HERE to purchase it).

Learn more about these trending techniques at these links:

Unfortunately, we won’t be having a trending class before this year’s Summit. So if you want to learn more, you will either have to read the book or have a course at your site. For an on-site course, contact us by CLICKING HERE.

What Causes Human Error

A senior manager (VP or COO) should be the sponsor of your efforts to improve human performance.

Poor human performance (human error) is probably the most expensive waste that your corporation faces. TapRooT® Users at a single site saved millions of dollars each year by implementing some simple fixes.

To make TapRooT® even MORE effective for improving human performance we have developed a whole new course:

 Stopping Human Error

Find out more about how this course can help you and your senior management by CLICKING HERE.

The course is based on a brand new book that is at the printers and should arrive just before the 2020 Global TapRooT® Summit.

When you learn the techniques in this course, you will want your senior management to know how Stopping Human Error can help them meet their improvement goals.

The Keys to an Effective Performance Improvement Program


We work with companies all around the world to develop “Roadmaps to Success.” And we’ve discovered that senior management finds the roadmap very valuable.

What is a Roadmap to Success? It’s a visual plan based on your company’s needs to help you achieve your senior management’s objectives.

How much does developing this plan cost? Nothing. We do it for free for our clients.

If you are a TapRooT® Client, CONTACT US to get started on your roadmap. Or attend the 2020 Global TapRooT® ® Summit (coming up on March 9-13 at the Horseshoe Bay Resort near Austin, Texas) to develop one for yourself.

And to really get things started, bring your management team to the 2020 Global TapRooT® ® Summit. Will they appreciate the experience? See this link and judge for yourself…



If you are thinking about using TapRooT® to improve performance, CONTACT US and we will help you see how TapRooT® Root Cause Analysis and a Roadmap to Success can help you achieve your corporate goals.

How to React and Save Their Jobs if a Real Crisis Occurs


At System Improvements, we like to see our clients win awards for improved performance. We believe that TapRooT® Users will find and fix the root causes of major accidents BEFORE they happen. How? By analyzing Precursor Incidents and effectively fixing their root causes by applying TapRooT® Root Cause Analysis.

But what happens if you don’t get far enough ahead fast enough and a major accident happens? You have to be prepared.

Senior management must be part of the solution rather than being seen as part of the problem.

When you are seen as part of the problem, the Corporate Board will lose faith in your leadership. Then you will be out.

Where have you seen this before?

The BP Texas City Refinery explosion. The whole corporate chain of command from the Refinery Manager to the CEO was gone in two years.

The BP Deepwater Horizon accident. Tony Hayworth was eventually seen as part of the problem and the board said “Good-Bye.”

And of course most recently, the 737 Max accidents and the firing of Boeing’s CEO.

Be proactive and stop these kinds of accidents or at least be seen as being effectively reactive after the accident occurs.

Keep Your Company Out of Trouble

Bring to your company the knowledge they need to stay out of trouble. Here your list to get the process started…

  1. Adopt and implement TapRooT®. We will be glad to get you started. CLICK HERE.
  2. Have your best investigators attend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course.
  3. Get a program started to Stop Human Error.
  4. Send a performance improvement team to the Global TapRooT® Summit (and your management team – see above).
  5. Build a Roadmap to Success.

That should be a good start. We will be glad to work with you to customize your plan and make sure that you get ahead of the curve and avoid surprises.

Career Development & Opportunities, Courses & Training, Human Performance, Implementation, Operational Excellence, Root Cause Analysis, Root Cause Analysis Tips
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