Episode 262 features a conversation between Dr. Ayers and Ken Reed, Vice President at TapRooT, focusing on the real purpose and power of Root Cause Analysis (RCA). The discussion emphasizes that incidents are painful enough—what matters most is learning from them so they never happen again.
Reed explains that RCA is about peeling back the onion to uncover the true underlying causes of an incident—not the superficial or convenient explanations. The goal is to understand why the failure occurred so organizations can prevent recurrence.
A major theme is rejecting the outdated mindset of blaming workers. Reed stresses that incidents almost always stem from systemic issues, not individual fault. Blame prevents learning and shuts down honest reporting.
The episode highlights how RCA works hand‑in‑hand with incident investigation.
Investigation gathers facts
RCA interprets those facts to identify root causes Together, they create a structured, repeatable approach to learning from failure.
Reed shares actionable insights for those new to incident investigations, including:
How to approach interviews
How to avoid assumptions
How to use structured RCA tools
How to communicate findings without blame
The episode is positioned as a starter guide for safety pros wanting to improve their investigation skills.
Incidents are painful—but failing to learn from them is worse.
RCA is about systems thinking, not fault‑finding.
A structured approach leads to better corrective actions.
Psychological safety is essential for honest investigations.
The goal is always the same: make sure it never happens again.
