January 25, 2024 | Mark Paradies

Where Do You Get Ideas To Improve Root Cause Analysis?

My Experience…

When I was assigned the job of figuring out how to improve investigations and root cause analysis … I knew that we were NOT finding the causes of human errors. But where would I get ideas to help make things better? The year was 1985, and there wasn’t an easy place to start …

No internet
No e-mails with upcoming courses
No conferences on the topic (maybe one talk at a nuclear industry conference’s breakout session)

I knew that the Institute for Nuclear Power Operations (INPO) was working on a system because they had tried to hire me to help create it.

So what did I do?

Started looking at the human factors research.
Networked with the folks I knew at our corporate headquarters, INPO, the University of Illinois, INEL, EPRI, and several utilities where I knew people.
Started trying to create a list of causes that encompassed the human factors research that I was familiar with.

This started the development of a system to find root causes that eventually led to the TapRooT® Root Cause Analysis System.

It was a long road with many lessons learned.

In 1988, we started System Improvements to help people improve their root cause analysis systems.

In 1990, we won a contract to help the US Nuclear Regulator Commission improve their analysis of human errors.

In 1991, we started working with our first oil and chemical company (Chevron) to improve their root cause analysis as part of their efforts to improve process safety. From there, our growth into all types of industries with incidents – incidents that need fixes to prevent recurrence based on the real root causes – has been … pretty dramatic.

In 1994, we held the first TapRooT® Summit (not named the Summit until sometime later). It had great speakers and 35 attendees. I cooked steaks for everyone as our closing session.

Why did we decide to have a summit to focus on root cause analysis and performance improvement? Because I thought that our clients needed it. They needed:

a place to learn the latest ways to improve human performance.
to network and share best practices they were testing and perfecting.
to hear about what we were doing to improve the TapRooT® System.
motivation to keep them at the “performance improvement grindstone.”

L M Astronaut — Linda Unger and Mark Paradies with 1997 Astronaut Keynote Speaker

Little did I know that this first conference would turn into an annual event that had hundreds of attendees who are some of the smartest people from around the world who are improving industrial safety, quality, patient safety, process safety, asset optimization, and operational excellence.

Linda1988 — Linda Unger with Summit attendee from South Korea in 1998

I would never have guessed that I would draw people from Australia, Indonesia, Malaysia, UK, Saudi Arabia, Tanzania, New Zealand, Colombia, Brazil, Canada, Mexico, South Africa, Russia, Denmark, France, and many other countries (even the USA!) to hear what we thought others needed to learn to make their performance great.