September 26, 2018 | Mark Paradies

Why is Picking the Right Root Cause Analysis System so Important?

Misunderstood Fundaments of Root Cause Analysis

Once again today I was struck with the importance of picking the right root cause analysis system. Why? Every time I see an industrial accident with a fatality, I can almost guarantee that the company has weaknesses in its root cause analysis of previous incidents. The company probably has a misunderstanding about the fundamentals of root cause analysis.

Screen Shot 2018 07 10 at 3 19 12 PM

Of course, you don’t have to take my word for this. After the Texas City Refinery explosion, the Baker Commission published a report that included this quote:

On page xiv of the report: “Although BP is improving aspects of its incident and near miss investigation process, BP has not instituted effective root cause analysis procedures to identify systemic causal factors that may contribute to future accidents. When true root or system causes are not identified, corrective actions may address immediate or superficial causes, but not likely the true root causes. The Panel also believes that BP has an incomplete picture of process safety performance at its U.S. refineries because BP’s process safety management system likely results in underreporting of incidents and near misses.

Doesn’t that sound a lot like what I am saying?

What Happens if You Pick the Wrong RCA System?

If you pick an ineffective root cause system, you won’t be finding and fixing the real root causes of incidents. Your people might THINK they are finding root causes (BP employees thought they were finding and fixing root causes) but the uncorrected root causes that are left uncovered will come back to haunt you when the problems cause a fatal accident.


How do you correct the weakness in your root cause analysis processes?

I started that journey in 1985. It eventually led me to use my human factors and equipment reliability knowledge to create the TapRooT® System. By 1991, we had a TapRooT® Manual and our first 2-Day TapRooT® Course. And that was just the start of our journey. We keep making the TapRooT® System better every day.

Over the years we have leaned from our research, our client feedback, our experience using TapRooT®, and our course feedback (we training about 10,000 people per year). We put that knowledge to work to improve TapRooT® year after year.

Every year we improve our training.

When we get new ideas that we need to share, we write new books (TapRooT® Manuals, TapRooT® Books, Root Cause Tree® Dictionary, and Corrective Action Helper® Manual). For example, we re-wrote the original TapRooT® Manual in 1992. And then..

  • TapRooT® Manual revision 1994.
  • TapRooT® Manual revision 1996.
  • TapRooT® Book in 2000.
  • TapRooT® Book revision in 2008.
  • TapRooT® Books starting in 2015 (with some still being worked on today).

And to spread the word about the latest TapRooT® improvements and other ideas about performance improvement, we sponsor the annual Global TapRooT® Summit. This is a great place to benchmark your root cause analysis system and get new improvement ideas.

That’s how we keep the TapRooT® system the best (in my opinion) root cause analysis system in the world.

If you want to improve your root cause analysis, I would start by attending a TapRooT® Course. For people in charge of their root cause analysis program, I would recommend the 5-Day TapRooT® Advanced Root Cause Analysis Training. Here is a link to the location and dates of our public 5-Day courses being held around the world:

What if you already attended a TapRooT® Class? I have three ideas …

  1. If you only attended a 2-Day TapRooT® Class, go to the 5-Day (link above). You will learn advanced techniques and practice the skills that you already learned.
  2. If you have one of the old TapRooT® Books, get the new books as they are released. I’ve posted links below to all of the latest releases by their titles.
  3. Go to the Global TapRooT® Summit. Benchmark, network, and learn the latest ideas for improving performance.

Here are the links to the latest books:

Help your investigators do a better job finding and fixing the causes of smaller incidents (precursor incidents) to stop major accidents by applying the best root cause analysis system – TapRooT®.

Courses & Training, Investigations, Root Cause Analysis, Safety
Show Comments

2 Replies to “Why is Picking the Right Root Cause Analysis System so Important?”

  • Randy Dixon says:

    Can I order the books. And if I can should I start with number 1 or is this old information.
    Thank you very much.
    Randy Dixon SHE Professional

    • Mark Paradies says:


      In a few months we will have a boxed set out (books 1 -8).

      I would start with 1, 2, 3, & 4 and read them in that order.

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