July 30, 2025 | Mark Paradies

Bad Advice – Root Cause Analysis Experts That Aren’t Experts

Experts Share Bad Advice

I know I’ve written about this before, but this week, I saw two videos and read one article about root cause analysis that made me shake my head. I hope that nobody else watched or read them or at least they recognized the bad advice.

What kind of falsehoods did they propagate? That:

Simple root cause analysis was just as good as complex root cause analysis.
Two data points in a row were a “trend” that needed action.
AI was the answer to your root cause analysis problems.

Since I’ve been studying human factors and root cause analysis for over 40 years, I shouldn’t be surprised that I know more about root cause analysis than most people. But what gets me riled up is people who profess expertise but don’t really know what they are talking about. They really aren’t experts, and they publicly promote bad ideas that don’t work.

Let me give you a couple of examples of the harm that could be caused by bad root cause analysis advice…

Someone Could Get Killed

I read an article answering the question:

“What are the different tools used to conduct a
root cause analysis (RCA)? How do the RCA tools work?

First, if you are an expert, you know that just listing all the RCA tools would take a page or more. I’ve seen 400+ page research papers that didn’t cover the topic adequately. To the expert’s credit, they said there were many RCA tools. But then the “expert” wrote:

“A simple tool can be just as effective
as a complex tool when applied effectively…”

That’s a bad answer.

First, the choice between simple and complex is a false comparison. (A false comparison is a frequently used trick by people trying to convince you that something is “just as good as” something else.)

The expert described two simple tools (fishbone diagrams and 5-Whys). The description of the simple tools was OK. However, the expert didn’t warn novice users about the limitations of these simple RCA techniques. An expert should know that:

These simple tools have inherent limitations.
These limitations have a proven scientific basis.
These limitations can’t be overcome by wishful thinking or becoming a more experienced investigator.

A new person (like the one asking the question) won’t know the limitations and will blindly follow the expert’s advice. The simple tools will cause the novice investigator to perform poor root cause analysis, and the incidents will happen over and over again. How do I know? I’ve seen it happen at pharmaceutical plants, hospitals, oil refineries, utilities, and manufacturing plants (to name just a few).

This bad expert advice could cost someone their life (because a precursor incident was not fixed with adequate corrective actions). Or the bad advice could cost the novice investigator their job when the incidents keep happening over and over again.

At a minimum, people will probably discover that their root cause analysis isn’t working and, if all techniques are equal, they may conclude that root cause analysis really doesn’t work. I saw an article about healthcare root cause analysis that came to this conclusion.

What they should have concluded was that the root cause analysis technique they were using and the corrective actions they implemented didn’t work.

Why would an expert give this bad advice? Because they really aren’t an expert. They are just repeating things they have been taught by other experts who didn’t know what they were talking about. These fake experts didn’t do the research needed to understand the topic thoroughly.

Very sad.

If you would like to know more about what root cause analysis should include – not to be complex but to be effective – read about the fundamentals of root cause analysis HERE, which many root cause analysis experts don’t understand.

Wasted Resources

There was a manufacturing facility that depended on old equipment that was no longer being produced or supported by the manufacturer. Each time one of the electronic parts in the equipment failed, there would be a certain amount of lost production. The downtime was starting to add up to be big bucks.

Previous root cause analyses using the 5-Why method found that the root cause was that the old part was defective. The corrective action was to send the old part to the shop for repair and replace it with one from the shop that had been previously repaired.

Why were they repairing the old part? Because there was no newer equipment available to perform this process, the company had purchased many spare parts so that when something went wrong, the parts could be replaced. Also, when parts failed, they were returned to the electronics shop to be diagnosed and repaired to keep a supply of the parts the company would need in the future.

However, the failures continued, and they seemed to be more frequent.

An engineer decided that they needed to do better troubleshooting and root cause analysis. So, the next time a failure occurred, he did a complete review of the failure and the troubleshooting.

First, he discovered that the parts were being sent back to the shop with no information about how the failure had occurred. The shop tested the components but often found they were working correctly and returned the part to the parts supply bin as a working part. Those parts were then used to replace another part when it failed in the field.

The engineer and the folks from the shop dug deeper into the failures. They discovered that some of the components were overheating in the field. By the time the components were returned to the shop and were tested on the workbench (sometimes several days later), they had cooled down and appeared to work correctly. Thus, parts that would overheat in service were being returned to the field and reinstalled, causing repetitive failures.

The engineer came up with a five-point plan:

That each of these parts was given a unique identifying label so that they could be tracked for repeat failures.
When parts failed, operators would tag and label the part with the symptoms of the failure before they were returned to the shop.
That the shop set up a test stand that could duplicate the field environment and test the parts under operating conditions.
That a troubleshooting procedure should be developed to ensure systematic testing of the parts.
That parts where the failure could not be diagnosed would not be returned to the field.
That additional cooling fans are added to the enclosures that hold the parts to reduce the operating temperatures.

Using this plan, the repeat failures were eliminated, and over a million dollars in operating expenses were saved in the first year.

Thus, poor, simple root cause analysis cost the company over a million dollars a year for this single problem. That’s quite a waste of resources.

Misleading Trends

I’ve often seen management waste resources trying to correct false trends.

I don’t want to get into the details of trending root cause analysis data. The techniques that were developed by Shewhart, Deming, and Wheeler. If you want to get into the details, I would recommend reading:

Performance Measures and Trending for Safety,
Quality, and Business Management

Or attend the pre-Summit course being given by Kevin McManus – The Best Ways to Use Data to Improve Performance – on September 29-30 in Knoxville, Tennessee, just before the TapRooT® Summit on October 1-3.

If the expert had read the book or taken the course, they would know that two or three data points in a row don’t make a trend.

What’s wrong with reacting to false trends? Scarce resources are wasted trying to correct normal variation. Deming explains that reacting to false trends causes greater variation and poorer performance.

What does this have to do with the article and videos? One of the videos talked about the new “AI” system in their root cause analysis software that would automatically detect trends and show the top ten root cause types that your company experienced.

What was wrong with the system? First, garbage in = garbage out. Since the system was not effective at accurately identifying root causes, the data was suspect at best.

Second, the AI had been trained to look for two or more data points in a row that were increasing or decreasing (greater or lower frequency) as a trend. Thus, trends were probably based on insufficient data and would produce many false trends (false alarms).

Third, it would automatically show you your top 10 root causes. Once again, if the root cause analysis isn’t accurate, the top 10 won’t be accurate. Plus, is it significant if a root cause is in the top 10 this month, if each month the list varies due to normal variation? Once again, wouldn’t this be acting on false trends?

Caveat Emptor – Let the Buyer Beware

There is a significant amount of bad advice going around. Anything from:

Root cause analysis is obsolete, to
Simple root cause analysis is good enough, and people in the field can’t understand anything more, to
Our great system might be hard to understand, but don’t worry, it has AI.

If you are looking for a root cause system, don’t get bad advice by talking to someone who isn’t a real expert.

Instead, verify their expertise BEFORE you listen to them. Or at least verify that the system they are telling you about has solid research behind it. Try some of these questions:

Do they really know what they are talking about? (What research have they done? What is their degree in? Who have they consulted with? Who are their references? How long have they been in business? What success stories do their clients share? Do they provide advanced training and a conference to learn even more?)
Is their training guaranteed?
How many people use their system? How many people are trained each year? What major companies have standardized on their system?
Can you test their system in a public course before you decide to adopt it at your facility?

If you want to learn more about root cause analysis fundamentals before you make your choice, CLICK HERE. Plus, learn about the “10 Musts” for evaluating a root cause system by CLICK I NG HERE.

What About TapRooT® Root Cause Analysis?

Are the TapRooT® Folks Experts in Root Cause Analysis?

See the background of the leaders of System Improvements (the TapRooT® Folks) at THIS LINK. But that is just a start. Want to know more? Here are some of the lesser known facts about Mark Paradies’ background at THIS LINK. Not only that, but the TapRooT® System has a long history with many experts contributing to the development. See THIS LINK for more information about TapRooT® RCA’s history.

Is TapRooT® Training Guaranteed?

YES! Here is the guarantee:

Attend a course. Go back to work, and use what you have learned to analyze accidents, incidents, near-misses, equipment failures, operating issues, or quality problems. If you don’t find root causes that you previously would have overlooked and if you and your management don’t agree that the corrective actions that you recommend are much more effective, just return your course materials/software and we will refund the entire course fee.

We stand by our product. We know it works.

How many people use TapRooT® RCA, and How Many People are Trained in TapRooT® Root Cause Analysis Every Year?

We train about 10,000 people to use TapRooT® Root Cause Analysis every year. We’ve been doing it for about 25 years. (And ten more years before that with lesser numbers in those years.)

I’d be glad to talk to you about our happy users, but you can find examples of our users’ success at THIS LINK.

The clients that I think are more intriguing are the ones I can’t talk about. They consider TapRooT® Root Cause Analysis to be their “secret advantage” and don’t want their competition to find out that they use TapRooT® RCA to improve quality, stop equipment failures, and achieve operational excellence (in addition to stopping human error and improving safety).

Here is a list of the industry leaders that have sent people to our Global TapRooT® Summit in the past few years…

No other root cause analysis solution provider sponsors a conference with the breadth of knowledge and the worldwide networking and benchmarking available at the Global TapRooT® Summit.

Consider attending the Summit and a pre-Summit Course coming up on September 29 – October 3 in Knoxville, Tennessee. Get more information HERE.

What About the TapRooT® Software?

The first TapRooT® Software debuted in 1991 (we think it was the first root cause analysis software). The first complete TapRooT® Software with a database was released in 1994. We applied for a software patent in 1998 and received two patents in 2002 (#6,463,441 and #6,735,597) for root cause analysis software (incident analysis and solution system) – the TapRooT® RCA Software.

It was quite an achievement for us to have the US Trademarks and Patents Office recognize the uniqueness of our approach to our database development and root cause analysis tools (especially the computerization of the Root Cause Tree® Diagram – a portion of which is pictured below from the original patent application).

We have continually improved our software (now cloud-based) and have won awards, including the 2018 Wolters Kluwer Technology Partner of the Year Award.

Our latest software version is version 6.17, and you can find out more about it HERE.

Finally, Can You Try TapRooT® RCA Before Having On-Site Training to Implement It?

Of course!

We have public courses around the world (see the upcoming schedule at THIS LINK). Not only that, but we encourage you to bring an example problem from your facility and analyze it in the course. See our course descriptions at THIS LINK.

Want to read more about why so many industry leaders recommend TapRooT® Root Cause Analysis and require it for their contractors? See THIS LINK.

The Choice Should Be Clear

I hope this helps you pick the right root cause analysis system and avoid the common bad advice.

If you need more information or just want to talk about what makes TapRooT® Root Cause Analysis so great, call us at 865-539-2139 or contact us by CLICKING HERE.

One Reply to “Bad Advice – Root Cause Analysis Experts That Aren’t Experts”

Mark Paradies says:

August 9, 2025 at 2:34 pm

OH NO! I saw another webinar today with more bad advice.

In the Q&A section, a viewer asked about some of the problems they were g with 5-Whys.

The “expert” said that 5-Whys was an excellent technique if an experienced investigator used it correctly.

The “expert” said that you have to know what questions to ask and have an open mind to lw the evidence where it leads. The investigator can’t start out with the solution or the destination in mind. The investigator has to try to start by taking a fresh look at the problem.

I guess the expert didn’t know that the lack of guidance in 5-Whys and the common problem of investigators steering the 5-Whys to their answer are embedded in most “humans” approach to problem solving and can’t be fixed by simply trying harder to have an open mind and not make assumptions and styeer an investigation to the conclusion they have already jumped to.

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