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Taproot Cause Investigation - Improvement Focus

Health and Safety

Case Studies

The Client:

A Mining Organisation based in Queensland.


The Brief:

To facilitate an incident investigation using the TapRoot root cause analysis process.

The incident involved a fire on a truck which caused extensive damage to the truck and adjacent plant. Fortunately there were no injuries or fatalities.

The facilitation had to be conducted on site within days of the incident and we were able to provide a trained TapRoot facilitator with mechanical engineering qualifications to meet that time frame.

The client wanted to ensure the other similar truck on the site was safe and could be returned to full service.

The culture of the client was to use the investigation to identify opportunities for improvements in their operations, rather than trying to find someone to blame.


Our Response:

The TapRoot facilitation normally involves open discussion with the parties involved in the incident to:

  • Establish the timeline of events leading up to and following the incident
  • Identify the conditions and facts relating to those events
  • Identifying the causal factors
  • Identify the root causes
  • Identify more widespread systemic or generic causes and
  • Identify possible corrective actions and risk control measures

For this investigation it was also necessary to examine the incident site and the burned truck.


The Results:

The TapRoot flow charts (Snapcharts), causal factors and recommendations were presented to the Chief Executive Officer and senior managers and agreement reached for implementation of high priority risk control measures, corrective actions and improvements to systems and processes.

The driver of the truck was somewhat relieved when the process revealed over ten causal factors which had nothing to do with his actions. Equally he was pleased to be advised that his prompt actions in raising the alarm would be a positive in his performance review.

Footnote: The TapRooT process is a proven process for getting to the nub of the matter when things do not go according to plan and it is not restricted to health and safety incidents.

Recently we used a TapRoot process to identify the causal factors relating to an unsuccessful Enterprise Bargaining Agreement process. Last year we used a TapRooT process for a construction company to investigate a structural collapse.



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