TapRoot® Root Cause Analysis

From TapRoot®:

"In finding root causes, our research shows that investigators need help seeing beyond their current knowledge to identify root causes.  This is especially true for identifying the causes of human error.  Most techniques (cause-and-effect, brainstorming, 5-Whys, etc.) don't provide guidance to help investigators beyond their current paradigms.  Thus, investigators fall victim to the "favorite cause" syndrome.  They look for, and therefore continually find, their favorite causes.  When the fixes for these favorite causes don't seem to prevent future similar incidents, management and the investigators don't seem to notice.  Perhaps this is because the incidents are fairly infrequent and, therefore, hard to trend.  But even when similar incidents happen frequently, over and over again, management frequently doesn't question the effectiveness of their root cause analysis and corrective actions."

"Because of this research, we know that a good root cause analysis tool needs to provide guidance for investigating human performance and equipment reliability issues.  This embedded knowledge goes beyond the knowledge of most investigators.  That's why System Improvements developed the Root Cause Tree ® diagram to help investigators see beyond their current knowledge and look for causes outside their favorite few."