2-Day Day 1 2019, No Videos

Changing the Way The World Solves Problems
The Essential
TapRooT® Techniques
System Improvements, Inc.
238 South Peters Road, Suite 301
Knoxville, Tennessee 37923 USA
Phone: 865-539-2139 Fax: 865-539-4335
e-mail: info@taproot.com
web: www.taproot.com
Course Agenda
Day 1 Day 2
Class Introductions and TapRooT® Introduction
Root Cause Tree® - Eliminating blame
TapRooT® System Overview - What you’ll be
learning Corrective Actions - Developing fixes
SnapCharT® Basics - Gathering Information Generic Causes - Optional technique
Causal Factors - Identifying the errors Reporting - Management presentation
SnapCharT® Case Study - Practice Frequently Asked Questions
Final Exercise - Putting what you’ve learned to

work
© Copyright 2019 by System Improvements , Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited. Page 1
Session Timeline
09:30 – 09:40 Introduction

09: 40 – 10:40 Taproot 7 step process
10: 40 – 10:50 Break
10: 50 – 12:00 Snapchart (Sequence Of Events)

12:00 – 13:00 Lunch Break
13:00 – 14:00 Causal Factors “ Definition & Identification”
14:00 – 15:30 SnapCharT® Case Study - Practice
Breaking the ice
• Have you been involved in or a part of an

incident investigation team using Taproot RCA
investigation before ?
• What are the incidents investigation

methodologies you are familiar with or have
practiced recently?
• Why do you think you should invest 12 hours of

your time in getting trained with Taproot
investigation? i.e, what is the value will you gain by
conducting incidents investigations using Taproot
technique?
Taproot ® Materials
1. Taproot Course Workbook
2. Using Taproot-RCA for Major

Investigations
3. Corrective Action Helper Guide
4. Root Cause Tree® & Dictionary®
5. Taproot RCA Tree® Categories
Root Cause Tree® Dictionary
Consistent &
Defendable:
Tree® & Dictionary® -
“Never the two shall
be parted!”
Consistent & Reliable

results
Evidence to say “yes”? =
= Select category good data for trending!
Evidence to say “no”?
= Eliminate category
TapRooT® System Overview - Where it all begins …
It is a well-accepted safety principle that

the operator who does something to cause
an accident is the last action in a chain of
actions. These pre-accident actions create
conditions that lead the operator to make
the wrong decision. They can take place
months and
even years before the accident.
These pre-accident actions / conditions are called

by various names such as, “potential-error
conditions”, “latent failure conditions”, “threats
and “Causal Factors”
© Copyright 2019 by System Improvements , Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited. 5 Page 6
TapRooT® System Overview - Where it all begins …
❑ What is a taproot ?
❑ TapRooT® System Overview
The TapRooT® Root Cause Analysis System is a robust, flexible system for analyzing
and fixing problems.
The complete system can be used to analyze and fix simple or complex accidents,
difficult quality problems, hospital sentinel events, and other issues that require a
completed understanding of what happened and the development of effective corrective
actions.
The 2-Day TapRooT® Root Cause Analysis Course teaches the essential techniques for
investigating precursor incidents and fixing them to prevent major accidents.
© Copyright 2019 by System Improvements , Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited. 7Page 7
TapRooT® System Overview
Is there an easier way to

investigate problems?
Do You Just need to

document the facts?
Do u need effective fixes to

eliminate repeated
occurrences?
Do u want to prevent
similar types of Incidents?
TapRooT® Process
Higher Risk, Major Impact Lower Risk, Less Complexity
Using TapRooT®
Let’s see how you would use TapRooT®

to perform an investigation
SnapCharT® Basics
SnapCharT®
• A visual timeline of
what happened
• Planning Tool
• Data Collection Tool
The SnapCharT® is the

basis for the rest of
your analysis
Developing your SnapCharT®
Events Incident Events
Use to develop QUESTIONS or ACTIVITIES required to fill the gaps:
People Involved? Physical?

Go see pothole
Interview employees
Check visibility
Paper for Activity? Recordings?

Parking lot maintenance Check security videos
requests/records
Sequence of Events
INTERVIEW & GET INFORMATION:

Lights Out for About 3 Days Pothole about 4" Deep
Parking Lot Lights Burned Out Pothole Reported 4 Weeks Ago
Employee Left Work After Dark Pothole Repair Work Order

Submitted - No Action Taken
No Work Order For Lights in
System
Conditions that Describe the Events
These are proven facts

and questions, NOT
Conditions
opinions, judgments, etc.
Conditions
Amplifying info about
an Event:
What? Why?
Building the SnapCharT®
Start by defining the Incident.
The Incident is the reason for the investigation.
Incident
The Incident defines the scope of the investigation.
What is an Incident?
The Incident is usually the worst thing that happened.
Spilled Gasoline?
Could be an environmental Incident
Gasoline Ignites?
Fire could be the Incident
Large Explosion?
This would probably be the Incident
NOTE: Probably also a Major Investigation!
Sequence of Events
Events are actions – active verbs One action per box
Sequenced in chronological order (real time)

Date/Time
What Who does
Who does Who does What does what after
what what what
equipment Incident
does what incident
Dashed box or oval = assumption … not yet proven fact

Use job titles/functions instead of names – reduces blame focus
To decide what goes into an Event, ask:

“Could I video record this action?”
Flow of Events
a) Build START to FINISH:

OR
b) Build FINISH to START: ??
OR
??
c) FILL - IN - THE - BLANKS: ??
How far back in time?

- As far as required for relevant and useful data
How far after the Incident?

- Until situation is stabilized
- Until response is complete and you can document
what happened
Add Conditions
What do I know about each Event?
Was there anything about this Event that was different than desired?
Clarifying facts/data Conditions use passive verbs:

• positive or negative is, was, has been, …
• quantified if possible
What Who does

Who does Who does
equipment Incident what after
what what
does what incident
Different Facts Data Is
More Info More Facts More Data Was
More About Conditions
Conditions
should NOT Conditions should be:
- Factual
include
- Non-Judgmental
action steps - Precise / Quantified
Conditions may be
actions NOT done
Conditions describe the Events :

• How / What / Where / Why / To What Extent / Under What Conditions
• How actions or equipment response was different from desired?
Example SnapCharT®
Who does what?
Lack of
action
General
information
Policy
information
Describes Inappropriate
event to or undesired
which it is action
attached
SnapCharT® Summary
Incident Condition
Tell what we know about an Event
Usually the worst thing that happened Some examples:
• How / What / Where / Why / To What
Extent/Under What Conditions
10/10/2018 7:30 PM • What required actions were not done?
• How did equipment fail?
Event • What was different from desired?
• Conditions should NOT include action steps
• Use job titles/functions instead of names
“Who does What?” • Conditions will be grouped with Events later
OR
0 What?”
“What does ALL items on chart should be:
- Precise & Quantified
• Include dates/times
- Non-Judgmental
• One Action Per Event
- Factual
• Sequence from Left to Right If Assumption/Unverified Fact:
• Something I can video record - Dashed Box
• Don’t draw lines until done
- Dashed Oval
SnapCharT Best Practices
Example Best Practice
Jane Doe pushes Operator A pushes Use employee titles; if more than one
1 pump #2B stop
button
pump #2B stop
button
individual with the same title, use A,B, C or
employee initials or ID #
Operator A pushes
Operator A pushes Operator A
2 pump #2B stop
button and verifies
the valve line up
pump #2B stop
button
verifies the valve
line up
Use only one action
and one verb per Event
Pump #2B stop Operator A pushes

3 button is pushed
by Operator A
pump #2B stop
button
Use active voice opposed to passive voice
Operator A pushes
4 Pump stopped Pump #2B stop
button
Be specific and precise when describing an
Event or Condition (quantify if possible)
SnapCharT Best Practices
Example Best Practice
Operator A did
Operator A did not
5 push the pump #2B
stop button
not push the
pump #2B stop
button
Events are not things that “did not happen”;
things that did not happen are Conditions
Operator A pushes
pump #2B stop
Operator A pushes button Information that explains an Event is to be
6 pump #2B stop
button but thought
it was pump #3B
Operator A
thought pump
captured as a Condition
#2B was pump

#3B
Operator A is
Operator A pushes
careless and
pump #2B stop
pushes pump
button
#2B stop button Be neutral and objective; do not use
instead of pump
7 #3B they need to
pay more
Operator A
thought pump
#2B was pump
judgmental or inflammatory statements
attention #3B
SnapCharT® Exercise
See exercise
write-up in
back of
Workbook
Exercise
Define the Incident first

Next, work on building the Sequence of Events and adding
Conditions
Event: Can I video record the action?
Include questions you can’t answer in dotted shapes with question mark
Don’t draw lines at this time
Continue Investigation?
After completing your

SnapCharT®, you may decide
not to continue with the
investigation if:
• There is nothing more to learn

from this investigation,
or
• The risk presented does not

match the company investigation
criteria.
Example
You may decide that the risk (probability times

consequence) of a repeat of this Incident is
small (mainly because the potential
consequence is small) and you will
stop the investigation.
Finding Causal Factors
Review the
information
on the
SnapCharT®
Finding Causal Factors
and identify
Causal Factors
Note:
These are
NOT Root
Causes!
CAUSAL FACTOR
A mistake, error, or failure that

directly leads to (or causes)
an Incident ,
or fails to mitigate the
consequences of the original error.
“Who did what wrong?” “Who did NOT do something?”

or or
“What did what wrong?” “What did NOT do something?”
Examples
Mistake or Error Failure

(Human Error) (Equipment Failure)
Something that someone: Equipment

Operator did not that:
leave container before
- should have done, butfails
didn’t attempting
- failed to free
Detector
spool job site
Rigger leaves
- did, but did wrong and -walks
didtowards
not work as
intended
Parking lot lights not toilets alone
- did, but had working
an unintended Rigger attempts to
outcome free spool
Using Safeguards to Find Causal Factors
Hazard Safeguard Target

(Energy)
Energy = Potential Hazard
Control of Energy Keeps You Safe
Mechanical Chain Brake Electrical Insulators
Drum Biological Sharps Bins

Chemical
Design
Pressure Mechanical Thermal Cool

Integrity Vest
Radiation Time, Distance, Height Fall

Shielding Protection
Noise Muscle
Hearing Protection Lifting Training
Power
Understanding Safeguard Errors
Mistake that
allowed Hazard to
be too close to
Target
Hazard Target
Mistake that Mistake that Mistake that Mistake that allowed
allowed Hazard to allowed allowed Incident to become
exist or to be too Safeguard to fail Safeguard to be worse after Hazard
large missing contacted Target
Causal Factor Questions
Ask 3 questions to help find Causal Factors:
1. What was the initiating error?
Mistake that allowed Hazard to exist or to be too large

Mistake that allowed Hazard to be too close to Target
2. What were the opportunities to catch or stop that error?
Mistake that allowed Safeguard to fail

Mistake that allowed Safeguard to be missing
3. What were the opportunities to mitigate the consequences of that

error?
Mistake that allowed Incident to become worse after Hazard contacted Target
Stop / Catch / Mitigate
Operator did not perform

Operator opened
second checkValve
Supervisor ‘A’ not review
did
of valve
Worker lit a cigaretteEmergency
in response did
instead of Valve
position ‘B’
the completed valve line-area not arrive within 15 minute
unauthorized
up requirement
Causal Factor Rules
1. Must meet definition of a Causal Factor
2. Group related information under the Causal Factor
3. Causal Factor should be at the top of its group
4. Do NOT put a Causal Factor under another Causal

Factor
5. Must be a “Who did what wrong?” or “What did what

wrong?” (includes “did NOT do”)
As long as it follows these rules, your Causal Factors

should work just fine!
Find Causal Factor
Possible Groups
Causal Factors
Technician wipes ?
Technician washes down IV Bags with Technician transfers Sterile Room Inspector tests
hands before sterile isopropyl IV Bags to Sterile Contaminated IV Bags with
handling IV bags pads with bacteria Room Bacteria Strip
covered hand
? Technician did ? SOP 18.06 does ?

not wear not require an inspection
sterile gloves prior to transfer
SOP 18.07
Inspector did ? requires inspection
not identify bacteria prior to final use
until Sterile Room
How would you

1. group
What was the initiating error?
these
Conditions into
3. What were the opportunities to mitigate the
logical groups?
consequences of that error?
Check the Rules!
Technician wipes ?
covered hand
?
Technician did ? SOP 18.07

not wear requires inspection
• Must meet definition of a Causal Factor
sterile gloves prior to final use
Causal Factor ? • Group information under the Causal Factor
under another Causal not Inspector did
identify bacteria
Factor at until Sterile Room • Causal Factor should be at the top
Causal Factor
the top? ? • Do NOT put a Causal Factor under another
SOP 18.06 does Causal Factor
not require an inspection
This is NOT someone prior to transfer • Must be a “Who did what wrong?” or “What
did what wrong?” (includes “did NOT do”)
making a mistake
A mistake, error, or failure that directly leads to (or causes) an Incident,
or fails to mitigate the consequences of the original error
Safeguards Check?
Technician wipes
covered hand
Inspector did
not identify bacteria
until Sterile Room
Technician did SOP 18.07

not wear requires inspection
sterile gloves prior to final use
1. Mistake that allowed Hazard to exist or to be

too large
2. Mistake that allowed Safeguard to fail
SOP 18.06 does
3. Mistake that allowed Safeguard to be not require an inspection
missing prior to transfer
4. Mistake that allowed Hazard to be too close
to Target
5. Mistake that allowed Incident to become
worse after Hazard contacted Target
Let’s Identify Causal Factors
– What was an initiating error?

• Driver did not see the approaching train
– What were the opportunities to catch or stop

that error?
• Gate could have come down in time
– What were the opportunities to mitigate the

consequences of that error?
• Driver could have stayed put or backed up
Stop / Catch / Mitigate
Crane Incident Causal Factors
Identify Causal
Factors using
Stop / Catch /
Mitigate
Causal Factors
Causal Factor Exercise
On your SnapCharT® from

this morning’s Hazardous Spray Incident,
identify Causal Factors using
3 Questions and Catch / Stop / Mitigate
3. What were the opportunities to mitigate the consequences of
that error?
Ask 3 questions to help find Causal Factors:
Mistake that allowed Hazard to exist or to be too large

Mistake that allowed Hazard to be too close to Target
Mistake that allowed Safeguard to fail

Mistake that allowed Safeguard to be missing
3. What were the opportunities to mitigate the consequences of that

error?
Mistake that allowed Incident to become worse after Hazard contacted Target
SnapCharT® Case Study -
Practice
Put Learning Into Practice
Let’s practice finding
Causal Factors!
1. Watch videos
2. Identify Incident
3. Find Initial Error
4. Find opportunities to:
Stop
Catch
Mitigate
Causal Factors
1. Identify the Incident

2. Find an Initiating Error
3. Find missed opportunities to:
Stop
Catch Include Safeguards that

worked or didn’t work, and
Mitigate new safeguards to prevent
the issue
Possible Causal Factors ?
• Pedestrian ducks under rope
• Workers did not identify area as hazard

• Rope was very generic
• No signs
• Others?
Causal Factors

Stop
Catch
Mitigate
Possible Causal Factors ?
• Crewmembers in line of fire of anchor chain
• Anchor chain breaks

• Others?
Causal Factors

Stop
Catch
Mitigate
Possible Causal Factors
• Weapon misfires
• Man looks down barrel
• Man did not keep gun pointing in safe direction
• Others?

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Changing the Way The World Solves Problems

SnapCharT® Basics - Gathering Information Generic Causes - Optional technique

Causal Factors - Identifying the errors Reporting - Management presentation

SnapCharT® Case Study - Practice Frequently Asked Questions

Final Exercise - Putting what you’ve learned to

09:30 – 09:40 Introduction

10: 50 – 12:00 Snapchart (Sequence Of Events)

• Have you been involved in or a part of an

• What are the incidents investigation

• Why do you think you should invest 12 hours of

2. Using Taproot-RCA for Major

3. Corrective Action Helper Guide

4. Root Cause Tree® & Dictionary®

5. Taproot RCA Tree® Categories

Consistent & Reliable

It is a well-accepted safety principle that

These pre-accident actions / conditions are called

❑ TapRooT® System Overview

Is there an easier way to

Do You Just need to

Do u need effective fixes to

Let’s see how you would use TapRooT®

• Data Collection Tool

The SnapCharT® is the

Use to develop QUESTIONS or ACTIVITIES required to fill the gaps:

People Involved? Physical?

Paper for Activity? Recordings?

INTERVIEW & GET INFORMATION:

Employee Left Work After Dark Pothole Repair Work Order

These are proven facts

opinions, judgments, etc.

Start by defining the Incident.

The Incident is the reason for the investigation.

The Incident defines the scope of the investigation.

The Incident is usually the worst thing that happened.

NOTE: Probably also a Major Investigation!

Sequenced in chronological order (real time)

Dashed box or oval = assumption … not yet proven fact

To decide what goes into an Event, ask:

a) Build START to FINISH:

c) FILL - IN - THE - BLANKS: ??

How far back in time?

How far after the Incident?

Clarifying facts/data Conditions use passive verbs:

What Who does

Different Facts Data Is

More Info More Facts More Data Was

Conditions describe the Events :

Who does what?

Pump #2B stop Operator A pushes

#2B was pump

Define the Incident first

Don’t draw lines at this time

After completing your

• There is nothing more to learn

• The risk presented does not

You may decide that the risk (probability times

A mistake, error, or failure that

“Who did what wrong?” “Who did NOT do something?”

Mistake or Error Failure

Something that someone: Equipment

Hazard Safeguard Target

Drum Biological Sharps Bins