Publish More Incident Investigation Examples
Reader’s Request
Several readers have requested that we publish more examples of accident and incident investigations. They asked for examples that we have investigated. They’ve asked for examples from TapRooT® Users.
We would like to post more on this blog, but there are reasons why we don’t.
Reasons We Don’t Publish More Examples
First, we don’t publish examples we perform because we are bound by non-disclosure agreements and the attorney-client privilege. When we are hired to facilitate an investigation, the topic is usually sensitive. Thus, the agreement limits our ability to discuss our work. In the most restrictive cases, we perform the investigation for an attorney, and it becomes part of the attorney’s work product. Thus, the likelihood that we share one of our investigations is 0%.
Second, many TapRooT® Users fall under the same limitations. Their company doesn’t want potential bad press from shared incident investigations. That’s especially true of written examples that will be in print forever (like those in a blog).
Third, some examples from third parties that don’t use TapRooT® RCA aren’t very good. We don’t want to pass along bad practices and have people think they are good practices.
What We Do Pass Along
We have several sources of public domain incident investigations that we pass along. These include aviation near-miss investigations (from aviation investigators such as the NTSB, the AAIB, or NASA’s Aviation Safety Reporting System), railroad accident investigations (from the ATSB or the RAIB), and chemical incidents (from the CSB).
We also have examples of successful improvements based on incident investigation in our Success Stories on this blog.
In addition, we discuss incident investigation challenges and successes during our TapRooT® SuperUser quarterly virtual meetings. To participate, contact Marcus Miller.
Finally, we have presentations of success stories and other investigations at the Global TapRooT® Summit. For more information about these sessions and the Summit in general, CLICK HERE.
If you would like to learn advanced techniques for incident investigation and root cause analysis, I would suggest attending a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course.
To see the upcoming dates and locations of our public courses, CLICK HERE.
