March 31, 2010 | Ken Reed

Root Cause Analysis Tip: Sometimes, “Stuff Happens”

What happens when it appears something completely unavoidable happens?  As an example, I was recently asked about a truck that struck a deer.  It was daytime, the operator was not speeding, he had seen other deer on the other side of the road and slowed down, he was not tired or in a hurry.  The collision resulted in very minor damage to the truck.  The investigator was not able to find any root causes.  What do you do with this?

These types of investigations can sometimes feel frustrating.  There must be something that we can find here!

Sometimes, there was just nothing done wrong.  All current policies were followed, the policies look good, and sometimes “stuff happens.”  When it appears that this might be the case, try the following:

1.  First, verify that all the information is correct.  I’m not questioning the integrity of the driver, but just make sure all the information makes sense and there aren’t any inconsistencies.

2.  Perform a Safeguards Analysis.  In this incident, what were the Hazards?  Targets? Safeguards?  In this example, the hazard was the energy of the moving vehicle.  The Targets are probably multiple:  the truck, the deer, and the driver.  Now ask yourself, “What Safeguards were in place between the Hazard and the Targets?”  You’ll find things like speed limit, seat belts, driver awareness, etc.
    Now, ask yourself the 5 Safeguards questions that are at the bottom of page 376 in the TapRooT® Book.  See if there were any mistakes made in the application of the Safeguards you found.

3.  If you are really adventuresome, you can try applying other optional TapRooT® tools.  A CHAP Analysis will give you a very detailed understanding of exactly what was going on at the time of the incident.  Maybe a Change Analysis will help you understand why we hit a deer this time, but not at other times.

    When all this is done, you may find that there were no mistakes made.  This puts you at the top of the Root Cause Tree®, under Natural Disaster / Sabotage.  Your analysis has found that there are not any root causes.  This is OK, as long as you are confident that your data is accurate and complete.  Sometimes, “stuff” really does “just happen.”  Note that this isn’t the norm, but it does occur.

    The next thing to think about are Corrective Actions.  Again, you can apply Safeguards Analysis to see if there are any new Safeguards that you might want to put in place.  Take a look at page 379 in the TapRooT® Book to see which new Safeguards (Corrective Actions) would be most effective.  For example, maybe something like those critter whistles that you put on your bumper may help by attempting to Remove the Target.  Additionally, this particular incident report stated that they see deer along this road almost every day.  Maybe we can Remove the Target by finding a different route that is less likely to encounter deer.  Probably not possible here, but something to consider.

    These are just some ideas.  When you get to this type of problem, ensure your investigation is accurate and complete, using the optional TapRooT® tools.  If everything looks good, then there may be no actual root causes, but there still may be opportunities for improvement.

Root Cause Analysis Tips
Show Comments

Leave a Reply

Your email address will not be published. Required fields are marked *