The Difference Between Root Cause Analysis Success and Failure
Examples of Root Cause Analysis Success and Failure
Three investigators perform root cause analyses on precursor incidents. They present their results to management. One achieves root cause analysis success. The other two? Failure. Here is what happens…
Example 1. The investigator presents the results of the investigation and the corrective actions to management. Management carefully reviews the results, asks some questions, and approves the investigation and corrective actions. Resources are assigned, due dates are specified, and the implementation will be tracked in a database. Once completed, the corrective actions are checked to see that they are effective. Once the effectiveness check is completed successfully, the investigation is closed out.
Example 2: The investigator presents the results of the investigation and the corrective actions to management. Management reviews the results, asks some questions, and approves the investigation and corrective actions. The investigation is closed out, and the report is published. Management expects that the applicable departments will implement the corrective actions, but no tracking of completion is performed, and there is no effectiveness check.
Example 3. The investigator presents the results of the investigation and the corrective actions to management. Management is critical of the investigator’s conclusions. They argue that the investigator didn’t reach the right conclusions. They tell the investigator to rewrite the report and specify corrective actions that they want to see in the report. These corrective actions have already been completed before the report was finished, so management closes out this report. No effectiveness review is ever completed.
Of the three examples above, which example is most likely to produce success?
Which example is most likely to result in a repeat incident?
What Are the Important Differences Between Root Cause Analysis Success and Failure?
First Example
In the first example, management was prepared. They knew that the investigator was well trained in an effective root cause analysis technique that met all the required fundamentals of root cause analysis plus more.
They had attended an executive leadership course that helped them be more effective when participating in an incident review. The course also helped them understand the root cause analysis process and the follow-up that was required to ensure that effective corrective actions were implemented and checked for effectiveness.
They had done their homework and had built a system to ensure the effectiveness of their improvement program that included incident investigation (see this book for more information). They had created a roadmap to success and implemented the steps needed to create and effective improvement program and continuously improve it.
Thus, in Example 1, management was confident in what they were doing and knew the investigator and the processes being used would be effective.
Second Example
In the second example, management made sure that the investigator was well-trained. But they had not gone beyond that.
They didn’t attend an executive leadership course, and they had not set up an effective improvement program that included tracking corrective actions and checking that the implemented corrective actions were effective.
Even if the corrective actions they approved would have been effective, over 70% of the time, they either weren’t implemented or were only partially implemented.
Thus, in this example, management wondered why they had repeat incidents and didn’t see greater improvement in performance.
Third Example
This is the worst example. The investigator doesn’t want to be there in the review meeting. He has seen management tear into other investigators and so has tried to give management what they want … but was unsuccessful.
Management sees their review as training for poorly prepared investigators. They know why the incident happened BEFORE the investigation was completed (before it was even started). They had already fired an employee and a contractor and disciplined a supervisor. They knew that if people would just try harder, these incidents would stop.
They weren’t sure how they had hired such ineffective workers or why the workers had such a bad attitude, but they had made an example of an employee and a contractor for their errors. They would talk to human resources about more effective pre-employment screening to hire better workers.
What do you think happened at this facility? Did you read about the accident in the press?
Do You Want Root Cause Analysis Success?
These examples aren’t nonsense. These examples are based on real-life companies/facilities that I’ve observed.
The question you should be asking is:
What do we need to do to be more like Example 1
and achieve root cause analysis success?
The answer is below…
What Do Senior Managers Need to Know About Root Cause Analysis Success?
If you’ve worked hard to conduct a detailed investigation, make sure you’ve gathered all the evidence, defined the causal factor, and found the root causes using the Root Cause Tree® Diagram. If you used the Corrective Action Helper® to develop good, solid, effective corrective actions and, if possible, removed the Hazards, and if you’ve verified that they meet the SMARTER requirements, then you have an excellent investigation to present to management.
The question is:
Has management done their homework
to achieve root cause analysis success?
What is management’s homework? I wrote about senior leadership and root cause analysis in a prior article – Senior Leadership and Root Cause Analysis.
But I didn’t highlight what could go wrong when leadership doesn’t recognize the right answer: root cause analysis failure.
If you have the ear of the right senior leader, then perhaps you should suggest bold action – holding a:
TapRooT® Executive Leadership’s Role in Root Cause Analysis Course
To discuss the course and get a quote to hold a course at your site, call 865-539-2139.
