May 7, 2008 | Mark Paradies

Reasonable Root Cause Requests


I’ve observed hundreds of companies and found that most incident investigations are carried out by untrained investigators in their spare time.

Even companies that train their investigators to use TapRooT® often assign investigators who already have full-time jobs that keep them busy 40, 50, or 60 hours per week. Where do investigators find the time to investigate? They do it in their spare time!


Managers think they get “something for nothing” when they ask for a quick root cause analysis in the investigator’s spare time. You never get something for nothing. “Spare time” investigations have costs:

– Poor investigations & corrective actions

– Repeat incidents

– Increased risk of big accidents

– Risk of regulatory action after a big accident or because of repeat incidents

– Increased liability when plaintiff attorneys show that management didn’t respond to previous incidents

– Overworked, disheartened investigators

– Investigators trying to dodge investigation assignments

– Disenchanted employees who look at investigations as a waste of time

– Inaccurate investigation statistics

– Loss of management’s faith in root cause analysis

That’s quite a list.

Perhaps economizing on investigations isn’t a good idea.


If investigating incidents in your spare time is bad, what is a good practice?

A measured response with a wise allocation of resources.

Let’s look at three examples.

Start with a simple incident. A simple investigation by a single investigator is adequate (unless something unexpected is discovered). The key is that the single investigator has to have the time to perform an investigation. Thus, this isn’t an investigation in the investigator’s “spare time.” You must relieve the investigator of his/her normal duties for a period of time. How long? A day or two for most simple investigations.

Next, let’s look at major investigations. Management seldom tries to have these performed in the investigator’s spare time. But, investigators are sometimes pulled away from the investigation to attend to their “normal” work. In this case, a full-time investigation team needs to be formed with an independent facilitator, a full-time team leader, an adequate team (some full-time, some part-time), clerical support, contractor support (specialty analysis and investigation support), and perhaps legal and public relations support. The size of the team and the duration of the investigation depends on the complexity of the accident and the investigation depth requested by management.

In between these two extremes lies the middle ground: investigations that require more than a single investigator but less than a full-blown team investigation. The size of these investigation teams should be based on the incident complexity and the expected return-on-investment of the investigation. Thus, management needs to provide dedicated resources that are proportional to the work and benefits.


For management to assign the appropriate resources, they must know the work required or have an investigation rule of thumb. Unfortunately, many managers haven’t performed a detailed root cause analysis and, because the work required for different investigations is so variable, there isn’t a “one-size-fits-all” investigation guideline for the work required. This means that management will have to start by assigning their best guess as to the required team size and then rely on the investigation team leader to request more support if needed. This won’t happen if team leaders are penalized for asking for help.

Management needs to keep asking, “Is there any help that you need?”


Where can management learn more about the resource requirements for investigations and the best practices of industry leaders? At the TapRooT® Summit!


Review the Incident Investigation & Root Cause Analysis Best Practices Track and the Management & Measuring Performance Best Practices Track for details.

Root Cause Analysis
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