The Most Common Mistake Investigators Make in a Root Cause Investigation

January 29, 2019

In my role as president of System Improvements, the company behind the TapRooT® system, I’ve seen many incident investigations. They come in all shapes and sizes, and from incident investigators from diverse backgrounds. Despite this great variety, you’d be surprised that there is one common mistake that investigators make in root cause investigations. What do you think is this common mistake? You might think about many good “candidates” – for example:

  • Not securing the scene
  • Poor interview questions
  • Confirmation bias
  • Stopping at human error as a root cause
  • Using the same old corrective actions that didn’t work in the past

You think that I would have a hard time picking the one most common mistake that investigators make. But it was easy. The most common mistake is:

Jumping to conclusions!

Almost every investigator does it.

You’ve seen it happen on LinkedIn posts, everyone knows the root cause of the “stupid” accident.

Your boss does it (“I know the root cause of that…”).

And you do it too!

The secret to avoiding this common mistake is to ask “what” and “how”, not “why.”

When you are asked to find the root cause (or causes) of a problem, start by asking “What happened?” and then “How did it happen?” because:

  • You start collecting information to support your findings rather than jumping to conclusions when you ask “What happened?” or “How did it happen?”
  • You are admitting that you don’t already know everything when you ask “What happened?” or “How did it happen?”
  • You allow someone else to talk (someone who may provide valuable information) when you ask “What happened?” or “How did it happen?”

A smart investigator doesn’t start with the answer. Instead, they ask “What happened?” and “How did it happen?” to fully understand and define the problem before you start asking why. Then they follow the remaining steps in the TapRooT® Root Cause System to avoid the other mistakes that many investigators commonly make. The identified root causes are then populated in Enablon, where incident and root cause trends can be analyzed, and corrective and preventive action plans and can launched.

View the recording of our webinar with TapRooT® to learn how you can enable a human factors-based incident investigation lifecycle, and how the integration of Enablon and TapRooT® facilitates the tasks of incident investigators:


Mark Paradies

President at System Improvements, Inc., TapRooT®