July 28, 2020 | Mark Paradies

Using TapRooT® RCA to Improve Incident Investigation and Identify Fixable Causes

Using TapRooT® RCA to Improve Incident Investigation and Identify Fixable Causes

Submitted by Bob Matthews
Team Mobil West

This success story was written in the past and is being updated to our most recent blog article format and is being reposted here. The example shows how improving root cause analysis (RCA), incident investigation, and developing more effective corrective actions by using the TapRooT® System can help companies improve performance. These lessons still apply today more than ever.


Prior to implementing the TapRooT® Root Cause Analysis System in 1993, we performed incident investigations but we often:

  • stopped at a level above the root cause;
  • missed root causes that were important;
  • placed blame rather than finding fixable system problems; and
  • didn’t have a consistent, convincing means to present our information to management.

Therefore, our challenge was to improve our investigation system so that we could better prevent repeat incidents (that can be dangerous and expensive) by implementing effective corrective actions that would be approved by management and implemented in the field.


In 1993, we trained six people in a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. The training helped us decide to go forward to implement the TapRooT® RCA System, rewriting our investigation procedure, and training a large number of people to use TapRooT® Root Cause Analysis (RCA) to investigate problems.

We decided to license our site to use TapRooT® RCA so that we could conduct our own courses based on the System Improvements’ copyrighted training material. One of the initial trainees became a Certified Instructor and over an 18 month period, he trained about 200 people to investigate problems by using TapRooT® RCA.

After our initial implementation, we also developed the capability to record our results in a database and trend the incidents’ causes over time.

Specific Example of How TapRooT® RCA Helped

How did TapRooT® RCA help us? The best way I can explain the impact of TapRooT® is to describe a specific incident that the TapRooT® System helped us investigate and prevent by identifying root causes that we could fix by implementing practical fixes.

The example was the investigation of a large fire at a process unit. The fire resulted in a complete unit shutdown. The systematic TapRooT® Investigation helped us identify the misapplication of steel in the process as one of the causes. But TapRooT® RCA didn’t let us stop there. We continued to look for the system causes that led to why the wrong steel was used. This allowed us to prove that we needed to perform a complete material verification (PMI or Positive Material Identification) to make sure that there were no other misapplications of steel in other similar parts of the process. This verification was expensive. Without the detailed proof and logical presentation tools that are built into the TapRooT® System, management might not have perceived the need to spend the money needed (and commit to the plant downtime needed) to complete this verification.

When we performed the verification, what did we find? The inspections identified three additional areas that needed repair. Any of these could have resulted in an additional fire and unexpected shutdown. Worse yet, a large fire could cause injuries or fatalities. By using TapRooT® RCA, we avoided these future problems that would have eventually occurred.

As part of the TapRooT® Process, we institutionalized our corrective actions by updating the PMI Policy. We also looked beyond the specific problem of this application of metallurgy to the generic problem of pipe-wall and pipe-joint thinning. (Having a database helps you develop a convincing argument that this isn’t just a one-time problem but rather is a repetitive problem that needs a refinery-wide system fix.)

Longer-Term Results

In January 1997, when performing the inspections implemented as a result of our previous TapRooT® Investigation, we found thinning of a piping joint on a process unit furnace. We shut down the furnace to make repairs that cost about $270,000. If the inspection (implemented after the incident investigation described above) had not been performed, the pipe would have failed. The cost of repairing a catastrophic failure would have been much higher (possibly ten times as high) and could have led to personnel injuries.

The long term impact of using the TapRooT® System has been so broad and pervasive that it’s hard to measure in dollars. Why? Because some improvements are made by people in the field and aren’t “documented” as being attributed to implementing TapRooT® RCA. Also, because we have so many improvement initiatives, it would be unfair to say that all improvement is due to TapRooT® RCA. Therefore, as in any large facility, the total progress being made is not the result of a single initiative but rather the cumulative impact of all improvement initiatives. However, I can point to specific incidents (like the one I described above) that TapRooT® RCA helped us develop effective corrective actions that would not have been developed before we started using TapRooT® RCA.

Lessons Learned

Here at the Team Mobil West, we are firm believers that the TapRooT® System provides us with the necessary tools to determine the true root causes of incidents. This saves us investigation time and saves us the pain of having repeat incidents that we know would cost millions of dollars and cause personnel injuries.

We have also learned that we needed to apply TapRooT® RCA “across the board.” If we applied TapRooT® only occasionally to just the biggest accidents, we would lose proficiency and miss opportunities to catch problems when they were small (before big accidents happened).

We also learned that we needed to trend root cause data from the incidents so that we could identify problem areas (generic causes), allowing us to eliminate whole classes of incidents by implementing generic system fixes. The TapRooT® Software Database helps us make convincing arguments to help management see the need to implement fixes that may be expensive or time-consuming.

Accident, Investigations, Process Safety, Root Cause Analysis Tips, Success Stories & Testimonials
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