March 30, 2021 | Mark Paradies

Follow-up: “Why Human Error is NOT a Root Cause”

E-Mail Response

The “Why Human Error is NOT a Root Cause” article set a record for the number of people who read it in the first 24 hours AND the number of e-mail responses – both positive and negative – that I received.

If I had to sum up the negative responses into one sentence, it would be:

“What about accountability?”


One specific comment was:

First, the root cause definition is:

The absence of a best practice or the failure to apply
knowledge that would have prevented a problem

The “knowledge” mentioned here is not the worker’s knowledge. The “knowledge” in the definition above is more “collective knowledge” of people around the world. The knowledge needed to improve human performance.

For more about the definition of a root cause, see:

Now back to general accountability of the employee.

First, accountability is covered in the Root Cause Tree® under Management System. It is more about holding people accountable. See the definition of “accountability NI” in your Root Cause Tree® Dictionary.

But what usually passes for accountability is BLAME.

You hold the worker accountable by blaming them after the accident. You see that the worker was trained, “Knew” what they were doing, and had done this before without making a mistake, SO … they must be at fault. They need to “take responsibility” for their error. We need to make an example of them with discipline.

But this leaves out many root causes on the Root Cause Tree®. What about the Basic Cause Categories of Human Engineering, Communications, Procedures, Work Direction, Quality Control, and Management System?

Root Cause Analysis

TapRooT® Root Cause Tree®

There is a specific spot on the Root Cause Tree® for someone who:

  • intentionally does not follow or apply a policy, rule, or procedure; and
  • that SPAC is generally followed by others; and
  • is positively enforced.

That spot is the Management System – SPAC Not Used with all the root causes under that near-root-cause category crossed off. If you read the Corrective Action Helper® Guide for this category you will find the place where we suggest that discipline may be used for corrective action.

However, in my extensive use of TapRooT®, I find that that that category is rarely used. Why? Because there are other root causes that are more applicable. What? Well, for one, there is Management System – SPAC Not Used – enforcement NI. And then there are all the other root causes under Human Engineering, Communications, Procedures, Work Direction, Quality Control, Management System.

So, TapRooT® does have a place for someone to be held accountable but we find that in industry, holding people accountable for mistakes that were NOT their fault is much more likely than the failure to hold people accountable for things that are their fault (they intentionally violated a well-enforced Standard, Policy or Administrative Control (SPAC)).

Learn More

If you would like to learn more about human error, root cause analysis, and human performance, I would suggest two courses.

Stopping Human Error

The first course I would suggest is the Stopping Human Error Course.

5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

This course was first taught back in 1992. It has been improved ever since. It teaches using the TapRooT® Techniques to find root causes but concentrated on finding the root causes of human errors. If you didn’t understand the discussion of root causes, Management System, and enforcement NI … you will after attending this course. For more information about the 5-Day TapRooT® Course and upcoming dates and locations, see THIS LINK.

Don’t Wait to Fix the Root Cause of Human Errors

Human error costs big bucks. It causes fatalities, major injuries, quality issues, equipment failures, and lost production. You can’t afford to wait to start applying best practices to stop human errors. Get registered for one of the courses above today.

Human Performance, Root Cause Analysis
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