Root Cause Analysis – Getting Beyond Blame

I review a LOT of incidents, either formal reports or short overviews. While most organizations say they want to focus on getting beyond blame, many investigations still end up centered on what an individual did wrong rather than why the event occurred.

First of all, I want to make it clear that there is nothing wrong with identifying a mistake. That is perfectly okay. If someone pushes the wrong button, misses a required review, or uses the wrong tool for a task, we have to identify those problems. In TapRooT® RCA, we call these Causal Factors. These mistakes will be the basis of the additional analysis that must be done. Understanding the root causes of why humans make errors is the basis of TapRooT® Root Cause Analysis.

And this is where most RCA processes fall down. Almost all investigations I review stop at the Causal Factor level. I see root causes and corrective actions that look like:

• Counseled the operator to be more careful
• The root cause was human error (no kidding)
• The operator lacked situational awareness
• The operator did not follow the procedure
• The mechanic used the wrong torque wrench

What is common about these causes? They point directly at the person. We are blaming the individual for the incident.

And you can already see the corrective actions that will come out of these types of “root causes”. They are going to be “correcting” the individual. “Counseled the mechanic on the importance of using the required torque wrench when assembling the component.” Like the mechanic doesn’t already know he should use the correct tool.

What we really need to do to get beyond blame is dig down and understand why smart people make bad decisions or errors. Other RCA systems just don’t do that. They stop at the error and then throw a penalizing corrective action in place. You can pretty much guarantee you haven’t fixed the underlying issues, and the problem will happen again.

As a human performance-based RCA system, TapRooT® will ensure you’re looking at the true root causes of the errors. For that mechanic using the wrong torque wrench:

• Was the correct tool available?
• Do supervisors ever observe this task?
• Is this a common problem with other mechanics?
• Is it only on the back shift that this occurs?
• Does he know he’s supposed to use a torque wrench for this task?
• What does the procedure say?
• Is there a QC step that should be in place for this task?
• etc.

There are lots of reasons people make mistakes and violate requirements. It’s rare that we just randomly decide to make these decisions, and we need to dig deep enough to find the root causes. If the RCA system doesn’t provide the proper guidance, you’ll probably stop at that causal factor level.

Don’t settle for just blaming your people. Look at the human performance issues that are pushing (or allowing) your team to make these errors. The corrective actions you put in place will be much more effective and long-lasting.

The difference between an average investigation and an effective one lies in what happens after the mistake is identified. If you want to learn how to move beyond blame, uncover the root causes of human performance problems, and develop effective corrective actions, join us for a 2-Day TapRooT® Root Cause Analysis course. You’ll leave with a practical process you can immediately apply to your investigations.