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TapRooT® Root Cause Analysis
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August 10, 2023 | Mark Paradies
CHANGING THE WAY THE WORLD SOLVES PROBLEMS…
THE TAPROOT® ROOT CAUSE ANALYSIS MISSION
A new TapRooT® User asked me why we have the “tagline:”
CHANGING THE WAY THE WORLD SOLVES PROBLEMS
I thought …
“That’s our mission.“
But people new to using TapRooT® Root Cause Analysis 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 Master’s Degree in Nuclear Engineering with a
specialization in human factors (a rather different master’s 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 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 (precursor
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 had 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 the TapRooT®
System.
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 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® RCA 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 that 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® RCA on a worldwide basis, and we
started planning to have an international base of instructors with the ability
to support languages other than English.
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, Canada, Mexico, Thailand, the UK,
Singapore, Norway, and Australia at the Summit. One of our international
TapRooT® Users told me about the difference TapRooT® RCA 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, we returned to our offices in Knoxville, Tennessee, and the
small staff discussed our 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 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 are when we are teaching TapRooT® Root Cause
Analysis 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 the TapRooT® System,
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:
* Books
* Training
* Software
* Instructor skills
* Facilitation skills
* Implementation advice
* Blog
* Summit
* Newsletters
* Videos (YouTube and Facebook)
* LinkedIn (Group and company page)
And we add new tools and training when we find a need.
That’s why in the past few years we’ve added new courses. For example:
* 2-Day Equifactor® Equipment Troubleshooting & TapRooT® Root Cause Analysis
Training
* 2-Day Stopping Human Error Course
* 2-Day Effective Interviewing & Evidence Collection
* 1-Day TapRooT® Executive Leadership’s Role in Root Cause Analysis
* 2-Day Auditing & Proactive Improvement Using TapRooT® RCA
* 3-Day VIRTUAL TapRooT® Root Cause Analysis Training
If you’ve had our standard 2-Day or 5-Day TapRooT® Training, you may want to
consider holding one of these courses at your site or attending one of our
public courses.
We’ve also introduced a subscription-based micro eLearning training we call
“TapRooT® eLearning Pathways.” Find out more at THIS LINK.
By the way, do you have the latest TapRooT® Books? The ten-volume set is
pictured above and you can order them by CLICKING HERE.
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 Global TapRooT® Summit is coming up. CLICK HERE for more information about
the Keynote Speakers and Best Practice Sessions.
IF YOU HAVE NOT TRIED TAPROOT® RCA…
Now is the time to give it a try!
For a complete list of upcoming public TapRooT® Courses, see:
https://www.taproot.com/store/Courses/
CHANGING THE WAY THE WORLD SOLVES PROBLEMS…
CATEGORIES
Root Cause Analysis
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Read More about Incident Investigation & Root Cause Analysis Success Stories
March 21, 2024 Is Human Error a Root Cause? (Updated) Read More about Is Human
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September 22, 2020 How to Become a Certified TapRooT® Instructor Read More about
How to Become a Certified TapRooT® Instructor
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