Let’s walk through a real incident using a hypothetical free PDF of the dictionary.
While the specific PDF is a paid resource (usually included when taking a TapRooT® course or buying the book TapRooT: Changing the Way the World Sololves Problems ), the power lies in the of the definitions. If you strictly define your categories before you start investigating, you are applying the same "good piece" of logic that the dictionary provides.
Investigators begin by asking 15 high-level questions. These questions guide them toward one or more of the seven "Basic Cause Categories" for human error. These categories are:
Is the label placed in a location hidden by other equipment? taproot root cause tree dictionary pdf free
: Did leadership provide the necessary oversight and policy?
: The dictionary effectively acts as a "human factors expert in a book," prompting investigators to consider issues like fatigue, job design, or alarm fatigue that they might otherwise overlook. Where to Find TapRooT® Resources and PDFs
Identifies issues with material or vendor quality. Communication: Analyzes how information was shared. Let’s walk through a real incident using a
The Root Cause Tree® is a structured, graphical decision aid. Think of it like a diagnostic flow chart for organizational failures. When an incident occurs (a spill, an equipment failure, a procedural deviation), you don’t start with "human error." You start with a —an action or condition that directly led to the accident.
Benefits of Using a Standardized Dictionary for Root Cause Analysis
Since many government agencies (like the DOE or NRC) use TapRooT®, technical reports often include detailed excerpts from the dictionary as part of their incident findings. Why the Dictionary is Essential for RCA Investigators begin by asking 15 high-level questions
The is a proprietary investigative tool designed by System Improvements, Inc. to help investigators consistently identify root causes by using a structured set of questions. Accessing the Dictionary PDF
Pinpoint the specific human actions or equipment failures that allowed the incident to happen.
Let’s say you have obtained a legitimate TapRoot dictionary PDF (or a government alternative). Here is how to apply it to a real incident: "A conveyor belt motor overheated and caught fire."