Using TapRooT® Root Cause Analysis

to Investigate Precursor Incidents

and Major Accidents
By Mark Paradies and Barb Carr
TapRooT® Root Cause Analysis is a systematic incident investigation
process to find and fix the root causes of precursor incidents, major
incidents, and audit findings.

This white paper describes how the TapRooT® System can be used to
find the root causes of a medium-risk environmental incident at a
chemical plant. We will compare the solutions developed using
TapRooT® Root Cause Analysis to the real corrective actions applied
after a similar incident at a commercial facility. Plus, we will provide
an overview of how TapRooT® Root Cause Analysis is used by
companies and the results achieved solving their toughest problems.

Why Do You Need Advanced Root Cause Analysis?

You can use TapRooT® Root Cause Analysis to investigate a major

accident, but no one wants to investigate a:

• Fatality • Major environmental damage

• Serious injury • Major quality issue or product
recall
• Regulatory issue • Serious production outage

That’s why we need to stop major accidents before they happen.

How can you find and fix the problems that may lead to a major
accident before it happens? By fixing the root causes of the precursor
incidents that warn us of impending failures.

I’ve never seen a major accident that didn’t have several, or perhaps a
dozen, precursor incidents that could have been investigated and used
to solve the problems and, thereby, stop the major accident. Why do
major accidents happen? Because people ignore the warning signs.
They don’t invest the effort, or they don’t have the knowledge, to find
the root causes of the problems and fix them before the next major
accident occurs.

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That’s why we developed the TapRooT® Root Cause Analysis System.
To help people go beyond their current knowledge to find and fix the
root causes of incidents with a guided method. TapRooT® Root
Cause Analysis helps companies learn from their experiences and
prevent incidents using one of two processes.

Two TapRooT® Processes

The TapRooT® System is documented in a series of

books1,2,3,4,5,6,7,8,9,10.
To keep the TapRooT® System as easy to use as possible, we created
two separate processes: one for precursor incidents and one for major
accidents.

TapRooT® Root Cause Analysis for Precursor Incidents

What is a precursor incident? You might think it is the same as a near-

miss but we define it a little differently.

Precursor Incident
Minor incidents that could have been a major accident
if one or two more Safeguards would have failed.

Investigating precursor incidents and implementing corrective

actions minimize the risk of a major accident occurring. The simple
process, shown below, was designed to make root cause analysis as
easy as possible (less time-consuming) while still guiding investigators
to the real root causes.

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The process starts by applying the SnapCharT® Diagram (example
shown later) to discover what happened. When you understand what
happened, you are ready to decide if there is something important to
learn. If not, you stop the investigation. Stopping the investigation
once you understand the incident isn’t worth investigating can save
time and avoid the wasted effort of implementing unnecessary
corrective actions.

If a precursor incident is worth investigating, the next step is to

identify the incident’s Causal Factors. A Causal Factor is:

Causal Factor
A mistake, error, or failure that, if corrected,
would have prevented the incident or mitigated its consequences.

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An incident may have several Causal Factors. Each Causal Factor
needs to be analyzed to find its root cause(s). Identifying the Causal
Factor’s root causes is the next step.

The Root Cause Tree® Diagram is used to guide investigators to root

causes. The process is explained later in this white paper.

Finally, the Corrective Action Helper® Guide/Module is used to help

investigators develop effective fixes (corrective actions) for the root
causes.

That’s the simple TapRooT® Process.

TapRooT® for Major Accidents

The second process, the TapRooT® 7-Step Major Investigation

Process, is shown above.

Note the similarities in this process and the 5-step for precursor
incidents.

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So, what are the differences between the 5-step investigation process
and the 7-step major investigation process?

1. More steps. The major investigation starts with planning and

looks for Generic Causes.
2. Optional techniques. The major investigation process includes
the Equifactor®, CHAP, and Change Analysis optional
techniques to help in the evidence collection phase of the
investigation.
3. No option to stop. In the simple investigation, we can stop if
there isn’t anything important to learn. But for a major accident,
you need to complete the investigation. Stopping isn’t an
option.

For more about the TapRooT® 7-Step Major Investigation Process

and investigating major accidents, read: Using TapRooT® Root Cause Analysis
for Major Investigations.4

Example: Environmental Incident at a Chemical Plant

The following is an example of the use of the TapRooT® System to

analyze a medium-risk, environmental incident (fish kill) at a
chemical plant. Please note that this incident is not intended to
represent an actual event at any particular location.

This investigation was performed using the simple (low-to-medium

risk) investigation process shown on page 2.

To shorten this example, the information collection portion of the

investigation is not shown. Rather, use of the TapRooT® System is
only demonstrated for the evidence organization (what happened),
root cause analysis (why it happened), and the development of
corrective actions (how to improve performance). The three main
tools in this example are the:

• SnapCharT® Diagram
• Root Cause Tree® Diagram
• Corrective Action Helper® Module

Step One: Find out what happened and draw a SnapCharT®.

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A SnapCharT® is a timeline of events that led to the incident but it is
also an information collection tool and a central repository for data
collected. Let’s see how this tool was used in our example incident.

During a normal night shift at a process plant, fish were killed when a
temporary water treatment unit overheated and released hot, low pH
water to one of the plant's outfalls. An investigation that included a
contractor representative (contract personnel were operating the
rented temporary water treatment unit) was conducted using the
TapRooT® System. The preliminary sequence of events is shown on
the following SnapCharT® Diagram.

After the preliminary SnapCharT® was completed, the investigation

team planned evidence collection and collected information to
further document the SnapCharT® from:

• interviews with all contract operators and their supervisors,

plant personnel at the process plant unit, procurement
personnel, and operations management
● collecting policies and procedures, timekeeping records,
activity-specific paperwork, information about the flexible hose
and the automatic shut-off
● walk through of the work environment
● examining PPE

With this information, a more detailed SnapCharT® (shown below)

was developed.

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Step Two: Is there anything else to learn?

The next step in the TapRooT® Root Cause Analysis Process is to

determine from the documented SnapCharT® if there is anything
else to learn. If there is nothing more to learn from this investigation
or the risk presented does not match the company investigation
criteria, we would stop the investigation. Review the example
SnapCharT® above. To avoid equipment failures and mistakes made
by the operator going forward, the answer to that question would be
“yes” – we have more to learn!

Step Three: Find Causal Factors Using the Causal Factor Worksheet

As mentioned, a Causal Factor is a mistake, error, or failure that, if

corrected, would have prevented the incident or mitigated its
consequences. To help investigators determine the Causal Factor(s)
with ease, TapRooT®’s Guided System includes the Causal Factor
Worksheet. The Causal Factor Worksheet helps the investigator
perform a safeguard analysis by asking questions the investigator
answers with information from the SnapCharT®. The Causal Factor
Worksheet also helps the investigator identify human errors and
equipment failures that might be missed otherwise. All new
information gathered on the worksheet is added to the SnapCharT®.
Errors, failed catches, and missing safeguards often lead the
investigator to the Causal Factors.

[See example on next page.]

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Below is an example of what a SnapCharT® would look like after all
of the information is collected and documented, and after all new
information from the Causal Factor Worksheet is added. Causal
Factors have been identified by the triangle symbol.

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The four Causal Factors are marked with a triangle and include all the
attached information. Each of the Causal Factors were analyzed for
root causes using the Root Cause Tree® Diagram and Root Cause
Tree® Dictionary. The following is an analysis of the Causal Factor:
“Operator did not fix cause of high temperature.”

Step Four: Find root causes using the Root Cause Tree® Diagram

In an actual investigation, all the Causal Factors would be analyzed to

find their root causes. However, to keep this white paper short, we will
only explain the analysis of a single Causal Factor – “Operator did not
fix cause of high temperature.”

The investigator starts at the top of the Root Cause Tree® Diagram
(shown below, the complete Root Cause Tree® Diagram is available in
Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents 3) and
works down the Tree using a process of selection and elimination.
The investigator thus asks and answers questions to identify the
specific root causes for this Causal Factor.

Operator did not fix cause of high

temperature

In this case, the Causal Factor “Operator did not fix cause of high
temperature” was identified as a Human Performance Difficulty (one
of the four major problem categories at the top of the Root Cause
Tree®) and the other three difficulty categories were eliminated.

When the Human Performance Difficulty was identified, the Tree

guided the investigator to a set of 15 questions called the Human
Performance Troubleshooting Guide (part of the Tree's embedded
intelligence). The first of the 15 questions of the guide is shown below.

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A “yes” to question 1 guides the investigator to look for root causes in
the Human Engineering and Work Direction Basic Cause Categories
on the back side of the Root Cause Tree® Diagram. The complete list
of Basic Cause Categories on the back side of the Tree are:

• Procedures • Training • Quality Control

• Communications • Management System • Human
Engineering
• Work Direction

Each category indicated by a "Yes" answer to the questions in the

Human Performance Troubleshooting Guide was investigated further
to see if it could be eliminated or if one or more Near-Root Causes
and related Root Causes contributed to the problem (and thereby
"caused" the incident). The Human Engineering Basic Cause Category
is shown below.

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For the “Operator did not fix cause of high temperature” Causal
Factor, four of the 15 questions were answered "Yes." The 15 questions
guided the investigator to review the following Basic Cause
Categories:

• Human Engineering • Work Direction

• Management System • Procedures

A screen shot (from the TapRooT® VI Software) of one of these

categories (Human Engineering) with the analysis completed is shown
below.

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When the analysis of all the Basic Cause Categories (not shown here -
Work Direction, Procedures, Management System) for this Causal
Factor were completed, the following root causes were identified:

1. Monitoring alertness needs improvement.

2. Shift scheduling needs improvement.
3. Selection of fatigued worker.
4. The "no sleeping on the job" policy needs to have a practical way
to make it so that people can comply with it.

That’s four root causes (or ways to improve performance) for this
Causal Factor.

Step Five: Develop fixes using the Corrective Action Helper® Module.

Once the root causes for all of the Causal Factors are analyzed, the
investigator uses the Corrective Action Helper® Module of the
TapRooT® Software to help develop the corrective actions for the
root causes. The Corrective Action Helper® Module helps
investigators:

1. Verify that they are addressing the real causes of the incident.
2. Develop corrective actions to fix the specific cause of the
problem by applying best practices and missing knowledge.

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 3. Develop corrective actions for the generic (or systemic) causes
(if applicable) for the problem.
4. Develop additional implementing actions needed to make the
corrective actions successful.
5. Find references to study the problem in detail and learn more
about potential strategies to eliminate the problem.

The following is an example of the guidance provided by the

Corrective Action Helper® module of the TapRooT® Software for
the root cause “Monitoring Alertness Needs Improvement” that was
identified for a Causal Factor of the Fish Kill Incident:

Check:

You have decided that the problem was related to loss of performance
over time while monitoring. (The job was too boring.)

Ideas:

1. You should consider recommending the following options: (Order

does not indicate preference.)

a. Provide an alarm to alert the worker and relieve the boredom of

monitoring.

b. Provide an automated monitoring and response system to replace

human monitoring and response. NOTE: this will probably leave
the worker in supervisory control. You will need to consider ways
to keep the worker informed as to what the automation is doing
and to clearly indicate why it is doing it. You should also consider
ways to keep the workers involved in the process so that they
maintain their situational awareness and maintain their manual
control proficiency.

c. Rotate the person monitoring more frequently. (Experiment to

find out how long they can monitor reliably and then rotate
people so that they only monitor for less than that time.)

d. Redesign the job to provide other tasks that don't compete with
the monitoring task to keep the person alert and involved. (For
example, playing the radio while driving.) Do not provide tasks
that compete for the same resource. (For example, reading a book
while driving.)

e. Provide false signals to keep the worker involved. However, you

should also consider that people may ignore real signals if they
become accustomed to receiving only false signals.

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 f. Consult the workers to see if they have ideas that would make the
task more interesting without conflicting with the monitoring
requirements.

2. Fatigue can also combine with monitoring alertness problems.

Consider training supervisors to understand that fatigued personnel
should not be assigned to tasks that require a high degree of
monitoring alertness.

3. Also, consider testing individuals for their alertness before assigning

them to a monitoring task.

4. Once changes have been approved, consider training the workers

about the changes and their intended impact.

Ideas for Generic Problems:

1. If monitoring alertness is a generic problem, consider recommending

a review of the jobs to redesign them and add more active tasks.

References:

For more information about vigilance and monitoring alertness, consider

reading:

The Psychology of Vigilance by D. R. Davies and R. Parasuraman, 1981.

Published by Academic Press, New York.

Engineering Psychology & Human Performance by C. D. Wickens, 1992.

Published by Harper-Collins, New York.

Again, the Causal Factors were:

1. Flexible hose ruptures

2. Operator did not fix cause of high temperature
3. Automatic shut-off does not shut down unit
4. Operator did not shut down unit after the alarm

After reading all the Corrective Action Helper® Modules for all the
root causes that were discovered and after considering the seriousness
of each, the potential for future problems, and the systemic (generic)
nature of each cause, the following corrective actions for all Causal
Factors/root causes were developed.

1. Replace the old, flexible hose with a new, tested hose.

(Causal Factor 1)

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 2. Develop policy on testing and use of equipment in
temporary situations. (Causal Factor 1)
3. Remove the jumpers and place the automatic trip feature
back in service. (Causal Factors 3 and 4)
4. Update automatic trip feature with new module to
prevent spurious failures. (Causal Factors 3 & 4)
5. Negotiate contract revision so that contractor must notify
and get approval from the facility prior to disabling any
alarm or automatic safety feature. (Causal Factor 3)
6. Move diesel driven compressor away from temporary
water treatment unit so that the alarm on the unit can be
heard. (Causal Factors 2 and 4)

Note that all the Causal Factors are addressed.

The corrective actions were reviewed to ensure they were SMARTER.

The SMARTER review is part of the development of corrective
actions in the TapRooT® System. When developing corrective
actions, they should be:

Specific – Specifically what must be done?

Measurable – Can we measure that it was effective?
Accountable – Who does it?
Reasonable – Is it worth doing (cost/benefit)?
Timely – Will it be accomplished soon enough for the risk
involved?
Effective – Will it solve the problem?
Reviewed – Does it have unintended consequences?

As time passes and data is accumulated, the root cause data should be
reviewed using Pareto Charts to detect potential areas for generic
improvements. Also, data could be reviewed using Process Behavior
Charts (either rate charts or interval charts, depending on the trends
to be observed) to detect negative trends or verify that improvement
has occurred. For more information about these advanced trending
techniques, see: TapRooT® Performance Measures and Trending for
Safety, Quality, and Business Management.8

Comparison of Results

A real incident similar to the Fish Kill incident was reported in an

industry trade magazine. A 5-Why analysis had been performed. It

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found that the root cause was the sleeping operator. The magazine
reported the operator had been fired because they had violated the
company's no sleeping policy. Compare the "fire the operator"
corrective action with the corrective actions presented using the
TapRooT® System.

Corrective Action Comparison

Real Incident TapRooT®

Analysis

1. Fire the operator.1. Replace the old, flexible hose with a new,
tested hose.
2. Develop policy on testing and use of
equipment in temporary situations.
3. Remove the jumpers and place the
automatic trip feature back in service.
4. Update automatic trip feature with new
module to prevent spurious failures.
5. Negotiate contract revision so that
contractor must notify and get approval
from the facility prior to disabling any
alarm or automatic safety feature.
6. Move diesel driven compressor away from
temporary water treatment unit so that the
alarm on the unit can be heard.
The real incident corrective action of firing the contract operator who
was asleep:

1. Is easy.
2. Provides an example to others that they need to be alert.
3. Is consistent with the company policy.
4. Seems effective in that no other operators are found sleeping
for several weeks after the contract operator is fired.

However, what factors were missed and left uncorrected and what
problems were created by the “fire the operator” corrective action?

1. No actions were taken to improve the equipment reliability

(either the reliability of the fire hose or of the automatic shutoff
and alarm).
2. No effective corrective actions were taken to improve
monitoring alertness. At best, only a temporary improvement in

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 alertness was achieved. In fact, the results of spot audits could be
nonrepresentative because operators may be "covering" for each
other to ensure that no one else gets fired. The moving of the
diesel (so that the operator hears the alarm) and the fixing of the
auto shutoff feature make the sleeping problem moot. Neither
of these were addressed by the “fire the contract operator”
corrective action.
3. After a contract operator is fired, other operators will view
future investigations with suspicion and will be less likely to be
fully cooperative. For example, would an operator admit that
they had nodded off? Would another operator "tell" on a fellow
operator if he or she found the other operator sleeping? Or
would they just "handle it on-shift" and not tell anyone? Would
covering up mistakes get in the way of effective learning from
mistakes?

Even though:

• advanced root cause analysis and developing corrective actions

is more difficult than blaming those involved, and
• the TapRooT® Investigation suggests more thorough and
potentially more difficult to implement corrective actions than
the "fire the operator" answer,

If the problem really needs to be solved (to improve industrial or

process safety, quality, or productivity), then advanced root cause
analysis and implementing effective corrective actions is worthwhile.

Will TapRooT® Work for Your Incidents and Accidents?

The TapRooT® System was developed to help investigators find root

causes of safety, process safety, and quality issues. It was not
developed from a fault tree nor is it used like a checklist. Instead, the
TapRooT® System combines both inductive and deductive
techniques with embedded intelligence to guide a systematic
investigation to find the fixable root causes of problems. The system
can be used either reactively (as in the example provided in this white
paper) to prevent the recurrence of precursor incidents or major
accidents, or the TapRooT® System can be used proactively to find
ways to improve performance before a major accident occurs.

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The TapRooT® System goes beyond the simple techniques of "asking
why," cause and effect, fishbone diagrams, or fault tree diagrams. The
TapRooT® System has embedded intelligence to guide investigators
to find root causes that they previously didn’t have the knowledge to
identify. As Albert Einstein said:

"It's impossible to solve significant problems

using the same level of knowledge that created them."

The embedded intelligence allows the TapRooT® System to be

simple to use by people in the field for investigation of low-to-
medium risk incidents and yet robust enough for even the most
complex major accident investigations.

Unlike other common root cause techniques, the TapRooT® System

is an investigation system. This means the tools and techniques in the
TapRooT® System are used in all phases of an investigation - from
initial planning through the collection of information and root cause
analysis to the development of corrective actions and the presentation
of an investigation to management or other interested parties. The
system is supported by patented TapRooT® Software that:

• makes presenting information easy and logical,

• provides trendable incident/root cause data, and
• includes a corrective action management database.

The TapRooT® System is used in a wide variety of industries,

including:

• Oil & Gas • Utilities and Nuclear Power

• Mining • Refining and Chemicals
• Pipelines • Telecommunications
• Aerospace • Aluminum and Steel
• Healthcare • Pulp and Paper
• Pharmaceuticals • Manufacturing
• Food and Beverage • Construction
• Mass Transit • Railroads
• Airlines • Shipping
• Government Facilities and Contractors

These industries use the TapRooT® System to:

• Improve industrial/occupational safety,

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 • Improve process and nuclear safety,
• Improve transportation safety,
• Improve product and service quality,
• Achieve excellent regulatory performance,
• Reduce environmental releases,
• Reduce human errors, and
• Increase service and equipment reliability.

A limited survey conducted in 2001 by the Center for Chemical

Process Safety11 showed that more CCPS Members used the
TapRooT® Root Cause Analysis System to investigate process safety
incidents than any other technique/process.

Over the years, TapRooT® Users have submitted many success

stories that are documented in the Success Story topic of the
TapRooT® Blog ([Link]/blog).

Thus, we believe that the TapRooT® System will work for the
problems you need to solve. That is why we can offer a money-back
guarantee for TapRooT® Training:

Guarantee
Attend the TapRooT® Training. Go back to work and use what you have learned
to analyze accidents, incidents, near-misses, equipment failures, operating
issues, or quality problems. If you don’t find root causes that you previously
would have overlooked and if you and your management don’t agree that the
corrective actions that you recommend are much more effective, just return
your course materials and we will refund the entire course fee.

The guarantee proves how confident we are that TapRooT® Root

Cause Analysis will work for your company’s incident investigations
and problem-solving efforts.

The best way to learn more about finding root causes using the
TapRooT® System is to attend a public or an on-site TapRooT®
Course. These courses will get you started:

● 2-Day TapRooT® Root Cause Analysis Course for investigating

low-to-medium risk precursor incidents
● 2-Day Equifactor® Troubleshooting and TapRooT® Root
Cause Analysis Course for people interested in finding the root
causes of equipment failures.

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 ● 5-Day TapRooT® Advanced Root Cause Analysis Team Leader
Course for people who may be called upon to investigate major
accidents or precursor incidents.

There is also an annual Global TapRooT® Summit for networking,

advanced topics, continuing learning, and refresher training.

Don’t allow human errors and equipment failures to repeat. Find and
fix the real root causes and prevent major accidents by using the
TapRooT® Root Cause Analysis System.

References

1. TapRooT® Root Cause Analysis Leadership Lessons by Mark Paradies

and Linda Unger. (2017) Published by System Improvements, Inc.,
Knoxville, Tennessee.

2. TapRooT® Root Cause Analysis Implementation by Mark Paradies and

Linda Unger. (2017) Published by System Improvements, Inc.,
Knoxville, Tennessee.

3. Using the Essential TapRooT® Techniques to Investigate Low-to-Medium

Risk Incidents by Mark Paradies and Linda Unger. (2015) Published by
System Improvements, Inc., Knoxville, Tennessee.

4. Using TapRooT® Root Cause Analysis for Major Investigations by Mark

Paradies and Linda Unger. (2016) Published by System
Improvements, Inc., Knoxville, Tennessee.

5. Using Equifactor® Troubleshooting Tools and TapRooT® Root Cause

Analysis to Improve Equipment Reliability by Ken Reed and Mark
Paradies. (2019) Published by System Improvements, Inc., Knoxville,
Tennessee.

6. TapRooT® Root Cause Analysis for Audits and Proactive Performance

Improvement by Mark Paradies, Linda Unger, and Dave Janney. (2016)
Published by System Improvements, Inc., Knoxville, Tennessee.

7. TapRooT® Evidence Collection and Interviewing Techniques to Sharpen

Investigation Skills by Barb Phillips and Mark Paradies. (2017) Published
by System Improvements, Inc., Knoxville, Tennessee.

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Copyright 2023 by System Improvements, Inc. All rights reserved.
8. TapRooT® Performance Measures and Trending for Safety, Quality, and
Business Management by Mark Paradies. (2018) Published by System
Improvements, Inc., Knoxville, Tennessee.

9. Improved Patient Safety with TapRooT® Root Cause Analysis by Ken

Turnbull and Mark Paradies. (2018) Published by System
Improvements, Inc., Knoxville, Tennessee.

10. TapRooT® Stopping Human Error by Mark Paradies and Joel Haight.
(2019) Published by System Improvements, Inc., Knoxville,
Tennessee.

11. Guidelines for Investigating Chemical Process Incidents, Supplemental

CDROM, (Second Edition). (2003) Published by the Center for
Chemical Process Safety, New York.

The figures and text in this white paper are copyrighted material and
are used by permission of System Improvements, Inc. Reproduction
without permission is prohibited by federal law.

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