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How Can Root Cause Analysis Help Improve Safety?

How Can Root Cause Analysis Help Improve Safety?

Root Cause Analysis can be one of the most effective analysis tools an organization can ever deploy (as long as people are shown how to use the process properly). So what is root cause analysis (or RCA for short) and where and when can it be used?

Root cause analysis is a systematic or step-wise technique that focuses on finding the real cause or causes of a problem or issue of any kind and then to deal with this cause or causes (once properly discovered), rather than just dealing with its symptoms. Ultimately, root cause(s), when found, help to prevent recurrence of this and any similar occurrences of this problem or issue in the future.

Although RCA is applied in a range of slightly different ways, in general it uses an ordered process as follows:

  1. A problem, issue or challenge is carefully defined or described in the most factual terms (gathering data and evidence about the incident in question (such as where, when, how, who etc.).
  2. Data and evidence is clustered and/or classified to create a timeline of events that led to an incident or accidents. For every behavior, condition, action, and inaction specified in the “timeline” the question can be asked what should have been done compared to what was actually done.
  3. The “why” question is asked multiple times to help identify the causes that may have contributed to the incident (going to deeper causes each time the question is asked).
  4. Possible solutions are identified, based on the root cause analysis that, when effective, would be likely to prevent recurrence with reasonable certainty, are within the organization’s control and do not cause or introduce other new, unforeseen problems.
  5. Once root cause(s) have been identified, and possible solutions have been evaluated, corrective action(s) or change(s) can be planned to help prevent recurrence of the incident. 

The Most Basic Root Cause Process: The Five Whys

The “five whys” technique is the most basic way to get to deeper or underlying incident causes. In this method an individual keeps asking “What caused or allowed this condition/practice to occur?” until you get to several root causes. Often the answer to each single one “why” uncovers another reason and generates another “why.”  It often takes “five whys” to arrive at the root-cause of the problem.

The Benefit of Asking the Five Whys is it’s:

  • Simple. It is easy to use and only requires people to think carefully about the incident.
  • Effective. It helps to quickly separate symptoms from causes and identify the root causes.
  • Thorough. It helps to get to the wider issues that may not be considered at the outset.
  • Flexible. It works well with other problem solving or trouble-shooting approaches.
  • Team-based. The best root cause analysis sessions are done by teams of people working together.
  • Cost-effective. The approach only needs people’s time. There is software that can be used for larger investigations but this is optional. 

So how does Root Cause Analysis lead to better Safety?

As a tool, RCA can help in a problem or challenge investigation, whether it is a process shortfall, equipment breakdown or reliability shortfall situation, a sales or marketing obstacle or even in a design or engineering challenge area. However, perhaps its most frequent area of use is in the realm of safety and accident or incident investigation in particular. This is because safety accidents and incidents are a surprise to organizations most of the time and may lead to more “knee-jerk” type reactions than they should. This can result in a quick and shallow investigation or one in which blame is sought (which happens even more frequently when an incident is high profile such as an air crash, large-scale fire, railway accident or employee death for instance).

What root cause analysis contributes in safety incident situations is to force investigators to take more time and to ask more insightful questions about what happened and to separate the conditions in which the incident occurred from the behavior(s) that also took place. It always introduces a logical process to follow which slowly reveals the many factors which may have contributed to the incident occurring, many of which are a long way from the guess or “gut feel” view that is formed at the outset.

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About Dr. Jon Warner

Dr. Jon Warner is a prolific author, management consultant and executive coach with over 25 years experience. He has an MBA and a PhD in Organizational Psychology. Jon can be reached at OptimalJon@gmail.com

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About the Editor and Primary Author

Jon Warner

Jon Warner is an executive coach and management consultant and in the past has been a CEO in three very different companies. Read more

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