Did management fail to enforce policies or provide enough resources?
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Without a dictionary, one investigator might look at a mistake and call it "Human Error," while another calls it "Poor Training." The Dictionary provides strict definitions for every node on the tree. It forces investigators to look at and ask specific questions to determine exactly why a failure occurred, rather than guessing. taproot root cause tree dictionary pdf free
: Checks if procedures were followed, available, or technically accurate.
Developed by Mark Paradies and Linda Unger, the TapRooT® System is a structured process designed to find and fix the root causes of problems, whether they appear in major accidents, low-to-medium risk incidents, or proactive audits. It moves beyond simple troubleshooting to provide a scientific methodology for root cause analysis, helping organizations prevent incidents and improve performance. Did management fail to enforce policies or provide
The is the visual backbone of this method. It resembles a decision tree that guides the investigator from a generic problem down to very specific root causes. The Dictionary is the companion document that defines every single box on that tree.
You can find full or partial versions of the methodology and dictionary on academic and archival platforms: It forces investigators to look at and ask
The wins for major investigations because it prevents "solution jumping." You cannot guess the cause; the tree forces you to follow evidence.
Evaluates instructions, checklists, and documentation.
If you need the real dictionary but cannot afford the full training course ($1,000+), here are practical alternatives:
: The U.S. Department of Energy offers free, public-domain root cause analysis guidance manuals and trees that can be downloaded legally in PDF format.