TapRoot® Cause Analysis Training Course

1. Introduction to TapRoot Methodology and Investigation Excellence

1.1 TapRoot System Overview

• TapRoot fundamentals including (7-step process, SnapCharT, Root Cause Tree, Corrective Action Helper)

• Investigation excellence including (systematic approach, repeatable methodology, quality standards, best practices)

• TapRoot 7-Step Process including (define problem, collect evidence, analyze, develop corrective actions, implement, track, share)

• TapRoot benefits including (investigation consistency, quality improvement, prevention effectiveness, organizational learning)

• Methodology comparison including (TapRoot vs. other methods, advantages, applications, selection criteria)

1.2 Investigation Principles and Quality Standards

• Investigation principles including (fact-based analysis, systematic approach, root cause focus, prevention orientation)

• Quality standards including (investigation quality, evidence quality, analysis quality, corrective action quality)

• Investigation types including (incident investigation, near miss investigation, problem analysis, performance analysis)

• Investigation scope including (boundary setting, depth determination, resource allocation, timeline planning)

• Legal considerations including (legal requirements, evidence preservation, confidentiality, reporting obligations)

2. TapRoot 7-Step Process and Investigation Planning

2.1 Step 1: Define the Problem

• Problem definition including (problem statement, scope boundaries, success criteria, stakeholder identification)

• Investigation triggers including (incident types, severity levels, investigation criteria, decision matrices)

• Investigation team including (team composition, roles assignment, competency requirements, independence)

• Investigation charter including (objectives, scope, methodology, resources, timeline)

• Stakeholder management including (communication, expectations, involvement, coordination)

2.2 Investigation Planning and Resource Management

• Investigation planning including (planning process, resource allocation, schedule development, risk assessment)

• Resource requirements including (personnel, equipment, facilities, information, budget)

• Investigation logistics including (site access, evidence preservation, witness availability, coordination)

• Quality planning including (quality objectives, quality standards, review processes, improvement mechanisms)

• Communication planning including (stakeholder communication, reporting requirements, feedback mechanisms)

3. Step 2: Evidence Collection and Information Gathering

3.1 Evidence Collection Strategy

• Evidence types including (physical evidence, documentary evidence, testimonial evidence, environmental evidence)

• Collection methods including (photography, measurements, sampling, interviews, observations)

• Evidence preservation including (chain of custody, integrity maintenance, storage requirements, documentation)

• Evidence management including (cataloging, analysis, verification, correlation, tracking)

• Information sources including (witnesses, documents, systems, experts, external sources)

3.2 Interview Techniques and Data Management

• Interview planning including (objective setting, question preparation, environment selection, timing)

• Interview techniques including (open questions, active listening, clarification, verification, documentation)

• Witness management including (identification, preparation, support, protection, follow-up)

• Data validation including (accuracy verification, consistency checking, reliability assessment, bias identification)

• Information synthesis including (data integration, fact compilation, evidence correlation, gap identification)

4. Step 3: SnapCharT Analysis and Event Reconstruction

4.1 SnapCharT Development

• SnapCharT fundamentals including (event sequence, conditions, actions, causal factors)

• Chart construction including (timeline development, condition identification, action mapping, factor analysis)

• SnapCharT symbols including (events, conditions, actions, causal factors, relationships)

• Quality criteria including (completeness, accuracy, logic, clarity, traceability)

• Chart validation including (evidence support, logic checking, peer review, stakeholder verification)

4.2 Causal Factor Identification

• Causal factor types including (condition causal factors, action causal factors, equipment failures, human errors)

• Factor analysis including (direct causes, contributing causes, underlying causes, systemic causes)

• Evidence correlation including (fact linking, consistency verification, assumption testing, gap analysis)

• Factor prioritization including (significance assessment, prevention potential, improvement opportunity)

• Quality assurance including (factor validation, evidence support, logical consistency, completeness)

5. Step 4: Root Cause Tree Analysis

5.1 Root Cause Tree Structure

• Tree structure including (basic categories, specific categories, root causes, generic causes)

• Navigation techniques including (tree navigation, category selection, cause identification, path following)

• Basic categories including (equipment difficulty, human difficulty, management system difficulty)

• Tree logic including (systematic analysis, logical progression, cause-effect relationships, prevention focus)

• Quality criteria including (thoroughness, accuracy, consistency, prevention orientation)

5.2 Root Cause Identification and Analysis

• Root cause definition including (management system causes, generic causes, specific causes, corrective actions)

• Cause verification including (evidence support, logical validation, alternative testing, peer review)

• Multiple root causes including (complex causation, interaction effects, system failures, organizational factors)

• Root cause prioritization including (significance assessment, prevention potential, feasibility analysis)

• Documentation requirements including (analysis recording, evidence linking, decision rationale, quality verification)

6. Step 5: Corrective Action Development Using Helper Tools

6.1 Corrective Action Helper System

• Helper tool structure including (root cause categories, corrective action types, effectiveness criteria)

• Action development including (prevention focus, system approach, effectiveness evaluation, feasibility assessment)

• Action categories including (training, procedures, design, management, culture)

• Helper navigation including (tool navigation, action selection, customization, optimization)

• Quality criteria including (effectiveness potential, feasibility assessment, cost-benefit analysis, sustainability)

6.2 Corrective Action Strategy and Planning

• Action strategy including (systematic approach, prevention focus, multiple barriers, defense-in-depth)

• Action types including (immediate actions, interim actions, long-term actions, systemic changes)

• Implementation planning including (resource allocation, timeline development, responsibility assignment, monitoring)

• Action integration including (action coordination, system integration, resource optimization, effectiveness enhancement)

• Change management including (stakeholder engagement, communication, training, support, monitoring)

7. Step 6: Implementation and Tracking

7.1 Implementation Management

• Implementation planning including (detailed planning, resource coordination, schedule management, quality control)

• Implementation execution including (action deployment, progress monitoring, problem resolution, adjustment)

• Performance monitoring including (progress tracking, milestone management, effectiveness measurement, reporting)

• Quality assurance including (implementation quality, standard compliance, effectiveness verification, continuous improvement)

• Stakeholder management including (communication, engagement, feedback, support, coordination)

7.2 Tracking and Performance Measurement

• Tracking systems including (action tracking, progress monitoring, performance measurement, reporting systems)

• Performance indicators including (implementation metrics, effectiveness measures, outcome indicators, leading indicators)

• Effectiveness verification including (measurement methods, data collection, analysis, validation, reporting)

• Corrective action review including (performance review, effectiveness assessment, adjustment needs, improvement opportunities)

• Continuous monitoring including (ongoing tracking, trend analysis, performance optimization, system enhancement)

8. Step 7: Knowledge Sharing and Organizational Learning

8.1 Knowledge Sharing Systems

• Sharing mechanisms including (reports, presentations, databases, training, communication systems)

• Knowledge management including (capture, storage, sharing, application, updating)

• Learning systems including (lesson learning, best practice development, knowledge transfer, application)

• Communication strategy including (audience identification, message development, channel selection, effectiveness)

• Organizational learning including (culture development, system improvement, capability enhancement, innovation)

8.2 Learning Culture and Continuous Improvement

• Learning culture including (openness, curiosity, experimentation, reflection, improvement)

• Culture development including (leadership commitment, employee engagement, behavior change, system support)

• Prevention culture including (proactive approach, risk awareness, prevention mindset, learning orientation)

• Continuous improvement including (system enhancement, process optimization, capability development, innovation)

• Performance measurement including (learning metrics, culture indicators, improvement tracking, effectiveness assessment)

9. Advanced TapRoot Applications and Complex Investigations

9.1 Complex Investigation Scenarios

• Multi-causal incidents including (complex causation, interaction effects, system failures, organizational factors)

• Organizational investigations including (management system failures, cultural issues, systemic problems, performance gaps)

• Recurring problems including (pattern analysis, systemic issues, root cause persistence, prevention failures)

• Major incidents including (significant consequences, complex causation, multiple stakeholders, regulatory interest)

• Special investigations including (regulatory requirements, legal considerations, expert involvement, external coordination)

9.2 Advanced Analysis Techniques

• Advanced SnapCharT including (complex timelines, multiple sequences, interaction analysis, system modeling)

• Advanced Root Cause Tree including (complex navigation, multiple paths, system analysis, organizational factors)

• Pattern analysis including (trend identification, recurring themes, systemic issues, prevention opportunities)

• System analysis including (system thinking, interaction analysis, emergent properties, complexity management)

• Innovation techniques including (creative analysis, alternative methods, technology integration, process enhancement)

10. TapRoot Quality Management and System Implementation

10.1 Investigation Quality Management

• Quality standards including (investigation standards, analysis quality, corrective action quality, reporting quality)

• Quality assurance including (quality planning, quality control, quality improvement, quality monitoring)

• Peer review including (review processes, quality assessment, improvement identification, standard maintenance)

• Investigation audit including (audit processes, performance assessment, compliance verification, improvement planning)

• Continuous improvement including (process enhancement, standard updates, capability development, innovation)

10.2 TapRoot System Implementation

• System implementation including (deployment planning, training delivery, competency development, support systems)

• Organizational integration including (policy development, procedure implementation, system integration, culture alignment)

• Competency management including (competency frameworks, training programs, assessment methods, certification)

• System maintenance including (standard updates, tool enhancement, training refresh, performance monitoring)

• Program management including (program oversight, performance monitoring, improvement planning, stakeholder management)

11. Technology Integration and Innovation

11.1 TapRoot Software and Tools

• Software applications including (TapRoot software, investigation tools, analysis capabilities, reporting functions)

• Tool integration including (workflow integration, data management, analysis automation, reporting enhancement)

• Technology benefits including (efficiency improvement, quality enhancement, consistency, standardization)

• Software features including (SnapCharT development, Root Cause Tree navigation, Corrective Action Helper, reporting)

• Implementation considerations including (training requirements, system integration, support needs, upgrade planning)

11.2 Innovation and Future Developments

• Technology trends including (artificial intelligence, machine learning, data analytics, automation)

• Innovation opportunities including (process automation, analysis enhancement, efficiency improvement, quality optimization)

• Future capabilities including (predictive analysis, intelligent systems, automated investigation, advanced analytics)

• Implementation planning including (technology evaluation, adoption strategies, change management, training)

• Continuous evolution including (technology monitoring, capability development, system enhancement, innovation adoption)

12. Regulatory Compliance and Legal Considerations

12.1 Regulatory Framework and Compliance

• Regulatory requirements including (investigation requirements, reporting obligations, standard compliance, documentation)

• Legal considerations including (legal requirements, evidence preservation, confidentiality, liability)

• Compliance management including (compliance planning, verification, monitoring, reporting)

• Regulatory interface including (authority communication, inspection support, relationship management, coordination)

• Documentation requirements including (investigation records, analysis documentation, corrective action tracking, compliance evidence)

12.2 Professional Standards and Ethics

• Professional standards including (investigation standards, competency standards, ethical standards, quality standards)

• Ethical considerations including (integrity, objectivity, confidentiality, professional conduct, responsibility)

• Professional development including (competency maintenance, continuous learning, skill enhancement, career progression)

• Industry standards including (best practices, professional guidelines, quality frameworks, performance benchmarks)

• Certification management including (certification requirements, maintenance, renewal, professional recognition)

13. HSE and Investigation Safety

• Investigation safety including (investigator safety, site safety, evidence handling, emergency procedures)

• Health considerations including (stress management, workload balance, support systems, wellbeing)

• Environmental factors including (environmental impact, sustainability, resource conservation, responsibility)

• Risk management including (investigation risks, safety protocols, emergency procedures, incident prevention)

14. Case Studies & Group Discussions

• Regional incident examples including (industry incidents, organizational challenges, cultural considerations)

• Complex TapRoot analyses including (major incidents, organizational failures, system breakdowns, recurring problems)

• Investigation challenges including (resource limitations, stakeholder conflicts, evidence challenges, time constraints)

• Success stories including (prevention achievements, culture change, system improvement, innovation examples)

• The importance of proper training in developing competent TapRoot investigators and ensuring investigation excellence