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LSMIKLE2  
#1 Posted : 20 January 2016 23:08:43(UTC)
Rank: Forum user
LSMIKLE2

Could anyone point me in the direction of good material on using the Taproot system please? Any advice/ direction would be highly appreciated. Thanks in advance. Regards LS
DeanoJ  
#2 Posted : 21 January 2016 04:39:45(UTC)
Rank: New forum user
DeanoJ

LS You looked at https://www.taprootfoundation.org/ ? Just a thought. There are also a few personnel on LinkedIn, which is another professional source. Taproot is used in the UK, but not significantly. Dean
RiskyBusiness  
#3 Posted : 21 January 2016 13:55:48(UTC)
Rank: Forum user
RiskyBusiness

Wrong link - try this one; http://www.taproot.com/ Proprietary materials handed out when you attend the approved course. Don't bother with the software though ;) Regards, Ross
jontyjohnston  
#4 Posted : 21 January 2016 13:58:52(UTC)
Rank: Super forum user
jontyjohnston

LS Be cautious about using Taproot can lead you down a lot of false trails in an investigation! J
LSMIKLE2  
#5 Posted : 21 January 2016 20:13:47(UTC)
Rank: Forum user
LSMIKLE2

Thanks very much for this DeanoJ and RiskyBusiness for the respective links. I will check these out once I get in. Very helpful. Jontyjohnston, I think with these softwares it is GI-GO so the User must have a wider understanding of the principles of causation and analysis. Thanks again everyone. LS
hilary  
#6 Posted : 22 January 2016 08:49:46(UTC)
Rank: Super forum user
hilary

I've done a 2 day TapRooT course and I have to say that it is a good system for the novice but for the experienced professional it compartmentalises too much. It will not accept that some accidents are, simply put, accidents which do not necessarily have a root cause - the operator had to be fatigued or the tools had to be wrong or the management system didn't work. The root cause - "operator tripped because he wasn't looking where he was going" does not compute with TapRooT. Let's face it, it does happen no matter how careful you are. The law of health and safety is that there is always one more idiot than you counted on. Bearing this in mind, TapRooT is, in my opinion, constrictive. If I was using TapRooT I would also be running another system like 5 whys or fishbone diagram to ensure I was not taken down the wrong path.
SHV  
#7 Posted : 22 January 2016 08:52:57(UTC)
Rank: Super forum user
SHV

jontyjohnston wrote:
LS Be cautious about using Taproot can lead you down a lot of false trails in an investigation! J
I totally disagree , i have used both Taproot and Kelvin Topset methodologies , it all depends of investigation team skills and expertise SHV
LSMIKLE2  
#8 Posted : 24 January 2016 09:10:51(UTC)
Rank: Forum user
LSMIKLE2

hilary wrote:
I've done a 2 day TapRooT course and I have to say that it is a good system for the novice but for the experienced professional it compartmentalises too much. It will not accept that some accidents are, simply put, accidents which do not necessarily have a root cause - the operator had to be fatigued or the tools had to be wrong or the management system didn't work. The root cause - "operator tripped because he wasn't looking where he was going" does not compute with TapRooT. Let's face it, it does happen no matter how careful you are. The law of health and safety is that there is always one more idiot than you counted on. Bearing this in mind, TapRooT is, in my opinion, constrictive. If I was using TapRooT I would also be running another system like 5 whys or fishbone diagram to ensure I was not taken down the wrong path. Hi Hilary, Sorry for my late reply. I have not used taproot per but I can remember distinctly from the different points users have put forward that I have used online incident reporting systems where it forced us down the ‘wrong path’ path. In cases where the user knew that the cause was more managerial he/she would still be lead to select operator error etc. simply because certain options were/ were not available because of an earlier choice. I have used different techniques such as the wishbone diagrams, fault tree, task analysis and cause mapping in the past for high impact incidents but I guess taproot is fine arrive at root cause and complete the investigation. Like most here caution, the user might not be arriving at the appropriate root cause. LS
LSMIKLE2  
#9 Posted : 24 January 2016 09:20:29(UTC)
Rank: Forum user
LSMIKLE2

SHV wrote:
jontyjohnston wrote:
LS Be cautious about using Taproot can lead you down a lot of false trails in an investigation! J
I totally disagree , i have used both Taproot and Kelvin Topset methodologies , it all depends of investigation team skills and expertise SHV
Morning SHV, I see your balanced perspective here. Might i infer that, where the user and team has good overall understanding and developed accident investigating skills then they should be able to mix methodologies achieve the goal. In situations where the user identifies a particular software/ technique is not the best for investigating a particular incident then a flexible approach should be taken. Infering from what Hilary suggested, maybe it would be best for the user to use an additional technique/ method to boost their efforts in arriving at the appropriate root cause. LS
RiskyBusiness  
#10 Posted : 25 January 2016 15:59:03(UTC)
Rank: Forum user
RiskyBusiness

One thing that I probably should have added is that I would ensure that the personnel (using whatever analysis tool you choose to use) get good investigation training - too many people confuse analysis with investigation. Ross
jontyjohnston  
#11 Posted : 26 January 2016 13:46:19(UTC)
Rank: Super forum user
jontyjohnston

Hilary summed it up nicely....... Too may investigations turn into post accident inspections and audits, identifying lots of factors that were not "causative" of the accident outcome. Using tools that send you looking for all those factors.....well.......what I said in the original post but with less words. J
martin1  
#12 Posted : 26 January 2016 17:11:31(UTC)
Rank: Super forum user
martin1

I once was required to do a Taproot for a chap who had fallen over his own shoe laces and broke a bone. Had he been trained in the importance of adjusting his PPE? Was the PPE the right size? Was there something in the environment that distracted him? Where did he put his shoes on - was the lighting in the locker room bright enough? Were the laces broken perhaps and therefore too short? Corporate asked for endless strands to the Taproot investigation. A grand waste of time. Taproot is OK but in the wrong hands beware mammoth overkill ( sounds like a good name for a heavy metal band?)
ChrisV  
#13 Posted : 27 January 2016 17:20:15(UTC)
Rank: New forum user
ChrisV

LSMIKLE2, Thank you for your question about TapRooT. I believe in honesty and transparency of who I am first before I post. As a TapRooT Root Cause Instructor with the company that created TapRooT, I wanted to clarify some of the statements written above. Misconception 1, " Not used often in the UK". Over 6,000 people trained in our courses in Europe alone. This number does not include courses taught by company certified instructors. This number does not include companies working in Europe that were trained in other continents. This does not include numbers of those who have participated as untrained team members in investigations done in Europe. Misconception 2,"Just good for novices. Experts are fine with 5 why's". Remember, it is not how many questions that one asks, it is what is asked. Some "experts", want to drive the root cause process (no matter which one they use). Driving creates bias and often throws away needed evidence. Shorter investigation does not equal a good one. Our process is used as a discovery process and has 7 expert systems built into it (Quality Control, Procedures, Human Engineering, Training, Work Direction, Communication). I have yet to see all those experts sitting in a room asking the 5 why's. Thus the number of repeat incidents you see from processes that are driven by the facilitator only or brainstorming. Misconception 3, "will take you down too many paths or rabbit holes." This is a misconception expressed by many of those untrained, those that want the answer to support their own derived root cause only or sad to say, a misconception sold by competitors. In some limited cases it is a perception based on not following the trained process. Our root causes are absences of best practices that lead to a causal factor. If one gets scope creep and identifies all the missing best practices that the company has but forgets to stay focused on the one causal factor that they are analyzing, then it is possible to list too many root causes. This is not design issue but an identifier that the person broke a few rules of the process. One correct concept is that not everything needs a TapRooT done on it. If you decide that a full investigation is not warranted and that root causes are not needed and that the risk of repeat is minor, then no TapRooT suggested or needed. High Potentials however should be investigated with TapRooT. There is NOT ONE major incident that I have investigated where this was the first time that the Causal Factors had occurred. Which means that this issue should not of occurred if the HP had been investigated using TapRooT or another structured process that guides the team. Feel free to contact me offline at vallee@taproot.com
jontyjohnston  
#14 Posted : 01 February 2016 14:10:19(UTC)
Rank: Super forum user
jontyjohnston

Interesting response Chris. I hold to misconception 3 but I am highly trained and experienced in investigative techniques and tools, never start an investigation on the basis that I will derive a root cause and offer no product so am I not a competitor. "Our root causes are absences of best practices that lead to a causal factor" is an interesting statement. So you start from the premise that best practices must be in place to prevent accidents, such that their absence creates a causal factor? How does that logic stand up when an accident is the direct result of a deliberate act of commission or omission by an individual? J
LSMIKLE2  
#15 Posted : 03 February 2016 23:31:02(UTC)
Rank: Forum user
LSMIKLE2

RiskyBusiness wrote:
One thing that I probably should have added is that I would ensure that the personnel (using whatever analysis tool you choose to use) get good investigation training - too many people confuse analysis with investigation. Ross
I totally agree with you RiskyBusiness.
LSMIKLE2  
#16 Posted : 03 February 2016 23:40:20(UTC)
Rank: Forum user
LSMIKLE2

ChrisV wrote:
LSMIKLE2, Thank you for your question about TapRooT. I believe in honesty and transparency of who I am first before I post. As a TapRooT Root Cause Instructor with the company that created TapRooT, I wanted to clarify some of the statements written above. Misconception 1, " Not used often in the UK". Over 6,000 people trained in our courses in Europe alone. This number does not include courses taught by company certified instructors. This number does not include companies working in Europe that were trained in other continents. This does not include numbers of those who have participated as untrained team members in investigations done in Europe. Misconception 2,"Just good for novices. Experts are fine with 5 why's". Remember, it is not how many questions that one asks, it is what is asked. Some "experts", want to drive the root cause process (no matter which one they use). Driving creates bias and often throws away needed evidence. Shorter investigation does not equal a good one. Our process is used as a discovery process and has 7 expert systems built into it (Quality Control, Procedures, Human Engineering, Training, Work Direction, Communication). I have yet to see all those experts sitting in a room asking the 5 why's. Thus the number of repeat incidents you see from processes that are driven by the facilitator only or brainstorming. Misconception 3, "will take you down too many paths or rabbit holes." This is a misconception expressed by many of those untrained, those that want the answer to support their own derived root cause only or sad to say, a misconception sold by competitors. In some limited cases it is a perception based on not following the trained process. Our root causes are absences of best practices that lead to a causal factor. If one gets scope creep and identifies all the missing best practices that the company has but forgets to stay focused on the one causal factor that they are analyzing, then it is possible to list too many root causes. This is not design issue but an identifier that the person broke a few rules of the process. One correct concept is that not everything needs a TapRooT done on it. If you decide that a full investigation is not warranted and that root causes are not needed and that the risk of repeat is minor, then no TapRooT suggested or needed. High Potentials however should be investigated with TapRooT. There is NOT ONE major incident that I have investigated where this was the first time that the Causal Factors had occurred. Which means that this issue should not of occurred if the HP had been investigated using TapRooT or another structured process that guides the team. Feel free to contact me offline at vallee@taproot.com
Good evening ChrisV, Sorry for the delay as I was on a short break with limited access. Thank you very much for your expert input and for clarifying some of the misconceptions about the Taproot system. I totally understand your reasoning behind misconception 2 and the reason why Taproots is one of the most widely used analysis tools. I will definitely PM you soon. Kind regards,
ChrisV  
#17 Posted : 15 February 2016 17:10:53(UTC)
Rank: New forum user
ChrisV

J, Great question, "How does that logic stand up when an accident is the direct result of a deliberate act of commission or omission by an individual?" In the TapRooT Process, if there are no missing or inadequate to standards, policies and administrative management system best practices and this is truly a one off deliberate action or inaction of the employee, then we recommend in our corrective action helper to proceed with the company's progressive discipline process. I always suggest that the investigation facilitator, state that this causal factor is an action or commission of policy with no management system root causes found, turned over over to HR or labor relations. Interesting enough, rarely to find the action of one to be a one-off behavior though.
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