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Efficient Yet Effective Root Cause Analysis

Posted by
Mark Paradies

Efficient root cause analysis should be what every company and industry strives for. Of course
you need effective root cause analysis, but why waste resources on root cause analysis if you
dont need to use them there? Thus you need efficient AND effective root cause analysis.
Of course all right-sizing, cutbacks, and efficiency initiatives have a dark side striving too
much for efficiency can lead to too little emphasis on quality. Thus companies need to make
sure that they dont devote too few resources to root cause analysis of problems. If companies
invest too little in root cause analysis, they will end up using even more resources by:

Having recurring incidents and repeating investigations that werent done correctly in
the first place,
Wasting effort on corrective actions that only address the symptoms and not the real
root causes,
Wasting management effort reviewing investigations and root cause analysis that isnt
as good as it should be (and therefore gets rejected by management)
Being cited by a regulator for poor investigations and inadequate root cause analysis
Having a major fine or your facility shut down over a regulatory issue that could have
been corrected earlier by good root cause analysis
Having a major accident that could have been prevented by good root cause analysis
of the prior incidents that were warning you about a problem (If only you had listened
more effectively!).

So devoting enough resources to root cause analysis without going overboard is the key to an
effective, efficient performance improvement program that you can continually apply and
which will produce a healthy return of the effort and $$$ invested.
So what are the keys to efficient yet effective root cause analysis? Read on and see
When I think of efficient, effective investigations, I think of using TapRooT(R).
TapRooT(R) was designed and has been improved over the years to provide a tool that
produces effective root cause analysis and investigation EFFICIENTLY. But to be efficient and
effective you need to use TapRooT(R) the right way.
What is the right way to use TapRooT(R) efficiently and effectively? Here are my TOP 10
suggestions for using TapRooT(R) efficiently yet effectively:
1. Sufficient training and practice for the investigation facilitator (team leader) and the
investigations team.


Assigning enough, but not too many, people to the investigation team.
Use investigation team efficiency strategies.
Get inside/outside help when needed.
Be prepared for an investigation BEFORE the incident/accident happens.
Dont waste time investigating small problems that dont deserve to be investigated.
Instead, use trending to spot developing problems from small issues and then apply
root cause analysis.
7. Keep up-to-date on current investigation best practices.
8. Use your TapRooT(R) Tools effectively to improve efficiency.
9. Get employees (not just team members) trained in the basics.
10. Get management trained.
Let me share a few more ideas about each idea so that you can apply these ideas and get the
most return on investment possible from your investigations and root cause analysis.
1. Training and practice for the investigation facilitator (team leader) and the
investigations team.

Lets talk about training first. Any professional knows that over training and practice helps a
team perform well when the pressure is on. Professionals at all levels (from the military to
professional sports to highly educated
The more serious the accident, the more the investigation team will be under pressure. Thus
the more training and practice they will need to assure good performance.
But even (or especially) for minor incidents, an untrained or poorly trained team can waste
considerable resources and make root cause analysis look like a waste of time.
Therefore, you must start thinking about OVER training your team leaders and team
So lets start out with what the recommended training. Then we can review OVER training.
Recommended Training:
Team Leader: the 5-Day TapRooT(R) Advanced Root Cause Analysis Team Leader Training
Team Member: the 2-Day TapRooT(R) Incident Investigation and Root Cause Analysis Team
Leader Course
Team Member (equipment analysis): the 3-Day TapRooT(R)/Equifactor(R) Equipment
Troubleshooting and Root Cause Failure Analysis Course

If your teams are trained to this level, you are NOT OVER-TRAINING. This will result in
inefficiencies in your root cause analysis. Especially for inexperienced investigators. In other
words, your training is meeting the recommended requirements but investigators will need to
gain experience to become efficient.
Think of the recommended training as the minimum octane that will make your car work. It
will run but it will sputter, backfire, knock, and be very inefficient under heavy loads.
But training isnt all that is needed. To keep the skills sharp, investigators and team members
need practice and feedback.
They should perform no less than one investigation per month.
They should get feedback on this investigation (both positive and negative feedback) from the
sites EXPERTS in root cause analysis a peer review committee of three or four of the best
The feedback should be aimed at:

Completeness of the investigation and consistency of use of the TapRooT(R) Tools

(complete, accurate SnapCharT(R) with all assumptions resolved, all Causal Factors
defined at the proper level, and proper use of the Root Cause Tree(R) especially the
Management Systems section)
Completeness and effectiveness of the proposed corrective actions (SMARTER and
evaluate using Corrective Action Helper(R))
Effectiveness of presentation


What should you do to overtrain your best investigators, team leaders, and team members?
Here are some ideas:
a) For a fairly large site or a corporate office, you should have several key investigators
who serve on the peer review committee (mentioned above). Over-Training for them should

Attending the TapRooT(R) Summit every year.

Attend advanced root cause analysis, incident investigation, human performance, and
equipment troubleshooting training every year. These could include courses given before
the TapRooT(R) Summit like the Stopping Human Error Course, the Coaching Skills
Course, the How To Interview and Gather Information Course, the Creative Solutions
Course, the Advanced Trending Techniques Course, or the Equifactor(R) Course.

Provide a presentation to investigation team members at their site and management about
the lessons learned from the Summit and the advanced training that they attended.

Attend at least one other professional conference about improvement topics of interest.

Read each issue of the Root Cause Network(TM) Newsletter and the TapRooT(R)
Friends/Expert e-Newsletter and subscribe via RSS feed to the Root Cause Analysis Blog.

Read the TapRooT(R) Book.

Consider volunteering to serve on the TapRooT(R) Advisory Board

b) All Team Leaders should:


Attend the TapRooT(R) Summit at least every two years.

Attend advanced root cause analysis training at least every two years.

Provide a presentation to investigation team members at their site and management about
the lessons learned from the Summit and the advanced training that they attended.

Read each issue of the Root Cause Network(TM) Newsletter and the TapRooT(R)
Friends/Expert e-Newsletter and subscribe via RSS feed to the Root Cause Analysis Blog.

Read the TapRooT(R) Book.

Attend the presentation by the key investigator about the Summit and the advanced

c) All trained team members should:


Attend refresher training at least once every two years.

Attend the 5-Day Course if they plan to progress to be a Team Leader.

Read each issue of the Root Cause Network(TM) Newsletter and the TapRooT(R)
Friends/Expert e-Newsletter and subscribe via RSS feed to the Root Cause Analysis Blog.

Read the TapRooT(R) Book.

Attend the presentation by the key investigator about the Summit and the advanced

A well trained (over-trained) team will make investigations look much easier and much more

2. Assigning enough, but not too many, people to the investigation team.

How many people should be on an investigation team?

If you cant count them on one hand, you probably have too many.
For really big investigations, you may decide to have a core team (maximum 10) and sub
teams for specific purposes (for example analyzing the failure of a particular piece of
equipment). These sub-teams can be thought of as an investigation within an investigation.
For smaller incidents you should have a team of only one or two investigators. YES one
investigator can be the team.
If your teams get too big, the team will waste tremendous amounts of time keeping everyone
informed and reaching consensus. This wasted time does not contribute to the quality of the
Dont forget, you can have technical experts who contribute but who arent part of the team.
Now, who should be ON THE TEAM?
1. A Team Leader
2. Someone technically familiar with the process/work (but probably not someone who
participated in the event)
3. Someone with influence/authority in the organization that will most likely have to make
changes as a result of the investigation.
Note that one person could meet all three of these criteria.
Note also that every organization and every technical discipline at your company needs
someone trained as a team member.
Final comment Keep your teams 5 or less will increase the efficiency of your investigations
dramatically. Going beyond 5 people starts an exponential increase in coordination of team
3. Use practices to keep the team efficient.
Team Leaders need to think about efficiency during investigations. They can use practices that
will help their team be efficient.
What tools keep a team efficient? Try these?

a) Use the Spring SnapCharT(R) to plan the investigation . Planning reduces needless
b) Think about interviews and schedule them to efficiently collect information and to
minimize interviewers and interviewees time.
c) Use no more than two investigators in an interview.
d) Dont waste time doing things in team meetings that could be done by one individual
outside the team meeting (for example, redrawing a SnapCharT(R)).
e) Call a temporary halt to the investigation and let people get back to their normal jobs if
analyses or information is delayed/wont be available for a period of time.
f) Keep an investigation to-do list and a meeting to-do list to keep the investigation
and meeting on track.
g) Let the investigation team know that you, the team leader, and management are
interested in investigation efficiency and effectiveness. Then track the hours spent and
find out why things are taking longer than planned.
h) Make sure that their is sufficient management support for an investigation.
Investigators cooling their heals waiting for people to interview, fights with contracts
over support purchase orders, or the inability to get a meeting room to use as the war
room for the investigation team should not occur or should be solved by
management support. The main challenge in getting an investigation done should not
be overcoming bureaucratic obstacles. If these obstacles are slowing down
investigations, get them solved once-and-for-all.
i) Have administrative assistance available for the team. Copying and other
administrative tasks should be handled by the appropriate staff.
4. Get inside/outside help when needed.
And investigation team needs to know when to get help and their should be pre-planned
assistance available for:

metallurgical analysis
oil analysis
human factors analysis
outside expert facilitators
accident reconstruction
technical experts on equipment
computer experts

Once upon a time, companies had their own internal experts. Now, most of this expertise has
been downsized. Make sure that you have planned to get this expertise when you need it.
(Contracts already in place before an accident even happens.)
5. Be prepared for an investigation BEFORE the incident or accident happens.
Have you prepared for investigations? Read Appendix A of your TapRooT(R) Book and then get
things prepared.

6. Dont waste time investigating small problems that dont deserve to be

investigated. Instead, use trending to spot developing problems from small issues
and then apply root cause analysis.
You need to make a clear dividing line between what needs investigating and what does not.
Things that get investigated should show a clear return on investment for the investigation.
Smaller problems should be trended.
Remember to ask the question:
To answer this question consider:
a. Are the consequences serious enough to be worth the effort of the investigation
b. What will be the return be on my investment in investigation time and effort?
c. Is this an failure that could lead to more serious failures or are the consequence
of this failure minor at best?
d. Is this a repeat failure that happens so frequently that stopping multiple repeat
failures is worth the investigative effort?
e. Is this some management, regulatory, or public relations hot button that may
be worth investigating for political reasons?
If the incident is not worth investigating, you should can record the event in a database so
that you can trend the failure type and location. Future data may show an increasing trend of
failures or an unacceptable rate of repeat failures.
Some may see this lack of small investigations as a problem. After all, if investigating big
problems and performing root cause analysis is a good thing, why not do more for smaller and
smaller problems?
First, most small investigations are done halfheartedly. That makes for poor investigations.
And since the problem is small, they dont get a peer review and get little management
review. because of a lack of effort, the real causes are not discovered and the corrective
actions are a waste of time and effort.
Second, no matter what your philosophy is about small investigations, eventually everyone
must agree that everything cant be investigated. So management needs to provide direction
and guidance for the appropriate cut off for root cause analysis.So consider developing clear
guidance. For example:
a. Serious Accident: The level of damage or loss caused by the accident means that this
investigation will probably get regulatory, senior management, shareholder, and potentially

public attending. The extreme consequences means that this will also be the most difficult
type of investigation. This type of investigation will take a dedicated team of highly trained
company investigators and consultants to conduct a thorough review of all evidence. The
complete suite of TapRooT(R) Techniques will be employed. A considerable investment in time
and resources will be required as well as senior management review or the investigation
results and potentially an independent review by a highly experienced outside reviewer. This is
obviously NOT they type of investigation imagined by this question.
b. Serious Incident: The level of damage or loss caused by this incident is worthy of
investigation and root cause analysis. This incident is serious because it cause damage just
below that required to trigger a Serious Accident investigation or because it could have
easily caused a Serious Accident with slightly different circumstances or without the
intervention of luck. This investigation will be similar to the investigation above with the
exception that some of the team members may be slightly less experienced, less consultants
will be used, and the review of the investigation will be by local management and an
investigation peer review committee made up of local investigation experts. Once again, this
investigation is above the minor investigation posed by the users question.
c. Incident: This incident caused minor damage or loss and there was at least one significant
safeguard (which was NOT luck) to keep the incident from becoming a Serious Incident. In this
case, a single investigator or a small investigative team may be used to perform the
investigation and only two tools will be used to perform the investigation: SnapCharT(R) and
the Root Cause Tree(R). These types of incident investigations will receive a brief review by
the peer review committee but will not receive management review unless a trend is
d. Recordable Event: These events are judged to NOT be worthy of investigations. The type
of event, organization, and the location are recorded in a database to allow trending. Since no
investigation is performed, no corrective actions are recommended and future recurrence of
the event is possible. Trends will be used to detect significantly increasing frequency of these
Here is a tip for the nuclear industry: All significant conditions adverse to quality should
be rated as an incident or above and therefore deserve root cause analysis. If it is not a
significant condition adverse to quality and it is not in another category that makes it
significant (cost, delayed startup, personnel injury, non-nuclear environmental release, ),
then a nuclear facility should categorize the problem and NOT waste time doing some sort of
halfhearted Apparent Cause evaluation that will waste time and corrective action effort
implementing fixes that arent effective.
7. Keep up-to-date on current investigation best practices.
Every year the TapRooT(R) Summit presents new good practices for investigations. These have
included ways to improve investigation efficiency and effectiveness. Recently, the Summit has

a whole track devoted to investigation best practices. Examples from the Summit planned for
April of 2006 include:

Establishing a just culture/No Blame Environment

Investigation/corrective action best practices session

Best practices for managing investigations with potential for litigation

Ranking the risks of your incidents

Ranking the importance of your corrective actions

Evaluating the effectiveness of your investigations

TapRooT(R) User best practices

Best practices for fast analysis of small problems

If each year you implement best practices for your investigations, you will have an industry
leading investigation program that is efficient and effective!
8. Use your TapRooT(R) Tools effectively to improve efficiency.
The TapRooT(R) System was designed to promote effective, efficient investigations. The
TapRooT(R) Software was designed to make the TapRooT(R) System even more efficient.
First, the software supports the investigator buy providing an easy-to-use tool for drawing
presentation quality SnapCharT(R)s.
Second, the software makes access to the Root Cause Tree(R) Dictionary a snap (just one click
Third, the results of your investigation are recorded while the analysis is performed. No need
to enter data separately.
Fourth, the Corrective Action Helper(R) Module provide great ideas for developing corrective
actions. This adds greatly to the efficiency and effectiveness of the corrective action process.
Fifth, the Equifactor(R) Troubleshooting Tables can help investigators develop troubleshooting
plans so that key equipment failure evidence is not lost and troubleshooting is done in the
most efficient/effective manner.

9. Get employees (not just team members) trained in the basics.

If employees know a little about root cause analysis, you will be surprised how much more
helpful they can be to the investigation team. They can:

save key evidence,

provide better information during interviews
suggest paths to help the investigation progress,
support the investigation recommendations

10. Get management trained.

There is nothing worse than performing a difficult investigation and then having management
fail to understand the lessons learned because they dont understand root cause analysis and
performance improvement methods.
The ultimate in inefficiency is having to rewrite and investigation report and add ineffective, or
worse yet counterproductive, corrective actions dictated by management.
Have you seen management mandate punishment when it wasnt called for by the
Have you seen management insist that more smaller problems be investigated even though
they didnt meet the investigation criteria?
Have you seen management insist there is a bad trend when there is way to little adata to
detect a trend?
have you seen management spend millions of dollars fixing problems that dont exist?
Root cause analysis and performance improvement training for management is probably one
of the best investments in time and $$$ that a company can make.
This training should be customized to meet the companys most pressing challenges.
ONE FINAL IDEA Proactive improvement is much more efficient than reactive
If targeted correctly, use of the TapRooT(R) Tools for proactive improvement is the most
effective/efficient improvement strategies that a company can adopt. If you are truly
interested in the efficiency of improvement, consider becoming more proactive with your use
of TapRooT(R). (Attend a 5-Day TapRooT(R) Advanced Team Leader Course or read Chapter 4
of the TapRooT(R) Book to find out more.
Category: Investigations, Performance Improvement, Root Causes, Summit