May 24, 2023 | Mark Paradies

Management System

Management System

Management System – The History

Back in 1985, my boss (Rod Satterfield) suggested I (Mark Paradies) look for better ways to analyze and trend root causes. I already understood human factors (from training for my master’s degree from the University of Illinois) and equipment reliability (from my experience in the Nuclear Navy). Therefore, I had a good start on the knowledge I needed to develop a system for root cause analysis.

The very first system I developed had a category (today, we would call it a Basic Cause Category) of Leadership.

When I showed the system to my boss, and he saw the Leadership category, he said:

“You have to take that out.”

He explained that senior management would go nuts if we said there was a leadership issue. We argued for quite a while. I said that management would just have to accept that they, too, could improve. He explained that I had done such a good job NOT having blame categories in the system that I shouldn’t have a blame category for leadership, and that’s how the company’s management would view a Leadership category.

Eventually, he convinced me that we could come up with a better name. He wanted to call it “Organizational Factors.” I said that it should be “Management.” He said that was just as bad as Leadership. He wanted to call it “Systems.” I thought that clouded the responsibility for where the changes needed to be made. Finally, I suggested “Management System.” It took a while, but he finally agreed.

After several management presentations and several discussions with senior management, we finally got approval for the “Management System” category.

Management System – The Start of a Term

Little did I know that we had invented a term that would be used around the world.


The first place it spread to was INPO (Institute of Nuclear Power Operation). I had interviewed for a job there, and they tried to hire me, but I had already taken another job. However, I stayed in contact with Joe Bishop, who was in charge of developing the HPES (Human Performance Evaluation System) system for INPO. When they had a version of the system ready, he sent me a copy for review. I commented that they had missed the Management System causes. Sure enough, my work on Management System made it into INPO’s HPES system.

From there, the terminology spread throughout the U.S. nuclear industry and to nuclear plants around the world.

Once I started System Improvements in 1988, the terminology started spreading to other industries. Refining, chemicals, oil exploration and production, and other industries. By the early 1990s, TapRooT® was adopted by industry leaders around the world. And the terminology “Management System” went with it.

Then, I began hearing the term “Management System” at professional society meetings. People started insisting that to find root causes, you needed to find management system causes. I thought this was interesting. Where had the term “management system” come from?

Internet Research

Recently, I researched the term on the internet and couldn’t find any references prior to the meeting I had with my boss back in 1986. In fact, it looked like the terminology had started widespread use (for example, in ISO Standards) in the mid-1990s.

I can’t prove it, but I think the terminology came from that meeting with my boss, Rod Satterfield. And that is how the Management System terminology got started.

What is the Definition of Management System?

Wikipedia quotes a FitSM standard for its definition of a management system:

a set of policiesprocesses, and procedures used by an 
organization to ensure that it can fulfill the tasks
required to achieve its objectives.

Wikipedia also quotes the international standard ISO 9000:2015 (Title: Quality management systems – fundamentals and vocabulary) definition in chapter 3.5.3 as:

“…a set of interrelated or interacting elements of an
organization to establish policies and objectives, 
and processes to achieve those objectives.”

Root Cause Tree® Dictionary

The TapRooT® Root Cause Tree® Dictionary asks this question to start the analysis of a Management System issue:

  1. Could an issue have been prevented by better standards, policies, or administrative controls?

There are 16 additional questions in just the first section of the dictionary to help investigators analyze management system issues.

Learn More About The Management System And RCA

If you would like to learn more about the Management System, all you need to do is read about it in the TapRooT® Root Cause Tree® Dictionary. You will receive a copy of the dictionary and will learn how to use it in any of our TapRooT® 2-Day or 5-Day Courses.

public TapRooT® course
Root Cause Analysis
Show Comments

Leave a Reply

Your email address will not be published. Required fields are marked *