7 Traits of a Great Root Cause Analysis Investigator
What Makes a Great Root Cause Analysis Investigator?
No, Inspector Clouseau was not a great root cause analysis investigator. But he was funny.
After decades of teaching TapRooT® Root Cause Analysis and being consulted about many investigations, I’ve met lots of root cause analysis investigators. Some were good … some were not so good but trying to get better. Some were great. Therefore, I thought it might be interesting to relate what I see that separates the best from the rest. Here are the seven traits of GREAT investigators.
- They don’t jump to conclusions.
- They understand what happened before they start finding out why it happened.
- They are NOT looking for a single root cause.
- They dig deeper to find root causes.
- They find fixable root causes and recommend effective corrective actions.
- They are professionals and know what they are doing.
- They continuously improve their investigation skills.
Each of these traits will be explained in more detail below…
Great Investigators Don’t Jump to Conclusions
1. They don’t jump to conclusions.
The worst investigators I’ve seen think they know it all. They already have their minds made up BEFORE the first interview. They START the investigation to prove their point. They already know the corrective action they are going to apply … so all they have to do is affirm that the causes they already have assumed ARE the causes they find.
Great investigators start by seeing where the evidence leads them. The evidence includes:
- Physical evidence,
- Paper evidence (documentation),
- People evidence (interviews), and
- Recordings (videos/pictures/tapes/computer records).
They are great at collecting evidence without prejudice. They perform “cognitive interviews” to help the interviewee remember as much as possible. (See the book TapRooT® Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills to learn more about cognitive interviews. Get the book with the Effective Interviewing and Evidence Collection Course being held as one of the pre-Summit Courses.)
Grat investigators may have technical knowledge, but they know when they need help to understand what the evidence is telling them. Therefore, they get technical experts when they need them.
Great Investigators Understand What Happened Before They Start Asking Why
2. They understand what happened before they start finding out why it happened.
The worst investigators start by asking WHY?
- Why did someone make a mistake?
- Why did the part fail?
- Why didn’t the guilty party use the procedure?
These “why” questions tend to put people on the defensive. People start justifying what they did rather than sharing what they know.
Great investigators start with what and how. They want to understand what happened and how those involved reacted.
- What did they see as the problem?
- What were the indications they were observing?
- Who did they talk to, and what did they say?
- What was happening, and in what order did it happen?
People don’t get defensive about what and how questions. They are much more likely to share information and tell the truth. And these questions help develop an excellent SnapCharT® Diagram that helps the root cause analysis investigator develop a “picture” of what happened.
Great Investigators Are NOT Looking for a Single Root Cause
3. They are not looking for a single root cause.
The worst investigators are always looking for THE root cause. The smoking gun. The one thing that caused the problem that a simple corrective action can correct.
Great investigators know that most accidents have multiple things that went wrong. They facilitate their team to understand all the Causal Factors and how these causal factors came together to cause that particular incident.
Great root cause analysis investigators use their SnapCharT® Diagram and Safeguard Analysis to show how the problems came together to cause the incident. This can help show management how latent conditions are hidden traps waiting to produce an accident that previously seemed impossible.
Great Investigators Dig Deeper to Find Root Causes
4. They dig deeper to find root causes.
The worst investigators stop when they identify simple problems. For the worst investigators, HUMAN ERROR is the root cause.
Great investigators know that human error is just a starting point for a root cause analysis. They go beyond equipment failure and beyond human error by using effective investigative techniques that help them go beyond their own knowledge.
For example, if there is an equipment failure, they consult the Equifactor® Troubleshooting Tables to find out more about the failure. This helps them get to the bottom of equipment problems. They often find that equipment failures are caused by human mistakes.
For human performance-related causal factors, they use the Human Performance Troubleshooting Guide of the Root Cause Tree® Diagram to help them determine where to dig deeper into the causes of human error.
The best investigators don’t accept false stories. They have a good BS detector because false stories seldom make a sense on a SnapCharT® Diagram.
Great Investigators Find Fixable Root Causes & Recommend Effective Corrective Actions
5. They find fixable root causes and recommend effective corrective actions.
The worst investigators find root causes that management can’t do anything to prevent (likje human eror).
What is the corrective action for human error? Tell the worker to “try harder” or be more careful. Does this change the system? No! Therefore the corrective action isn’t effective.
The worst investigators recommend the three standard corrective actions for almost every problem:
- MORE TRAINING.
- COUNSELING (tell them to be more careful and fire them if they get caught making the mistake again).
- If you are desperate, WRITE A PROCEDURE.
That’s about it.
What about great investigators? They understand that trying harder is important but that it is not a long-term solution. They look for human factors-related fixes that come from human performance best practices. They know that the Root Cause Tree® Diagram can help them find the root causes of human errors caused by problems in one or more of these Basic Cause Categories…
- Procedures
- Training
- Quality Control
- Communications
- Management Systems
- Human Engineering
- Work Direction
And by implementing best practices related to the root causes, they can reduce the probability of future human errors.
Great root cause analysis investigators understand the risk represented by the incident. Higher-risk incidents deserve higher-order corrective actions. The highest order is to remove the Hazard.
Other corrective actions may relate to strengthening the Safeguards by implementing human performance best practices. Sometimes, these corrective actions may include training and procedures, but they are seldom the only corrective actions recommended.
Great Investigators Are Professionals and Know What They Are Doing
6. They are professionals and know what they are doing.
The worst root cause analysis investigators are amateurs. They haven’t been trained to find root causes, and the training they received was superficial at best. (They ask “Why?” five times.)
Great root cause analysis investigators are accomplished professionals. They’ve been to advanced root cause analysis training and have practiced what they have learned by performing many investigations before they were asked to jump into a major investigation. Even if they have several major investigations, they continue to practice their root cause analysis skills on simple investigations and proactive audits and assessments.
Great investigators welcome feedback on their investigation. They participate in peer reviews and investigation grading. What is grading and investigation? Read THIS ARTICLE. Or watch this Summit presentation from 2015…
The grading tool mentioned in the video above is now part of the TapRooT® Software.
Great Investigators Continuously Improve Their Investigation Skills
7. They continuously improve their investigation skills.
The worst root cause analysis investigators avoid performing investigations and forget what they learned in the limited training they initially had. They certainly don’t want advanced training, refresher training, or benchmarking with great investigators.
What about the great root cause investigators? They attend the only worldwide summit focused on root cause analysis and investigation facilitation – The Global TapRooT® Summit. At the Summit, they benchmark their skills with other great investigators from around the world and share best practices. Think of this as steel sharpening steel.
GOOD NEWS! You Can Be A Great Investigator!
The knowledge and skills that make great investigators CAN BE LEARNED.
Where? CLICK HERE for a list of potential courses.
Also, attend to keep your skills sharp and learn even more best practices, attend the Global TapRooT® Summit every year to network, benchmark, sharpen your root cause analysis skills, and learn new investigation best practices. This will keep you a great investigator.
