Evaluate your RCA System!
I often find that companies think they have a good RCA system in place. They feel their system is providing corrective actions and improvement opportunities. I then ask how they came to that conclusion, and I don’t usually get good answers. At this point, it’s often a “gut feel”. They assume things are going well, but it is often a case of “you don’t know what you don’t know.” If you don’t know what a good RCA system looks like, you just don’t have anything to compare it to.
I recommend that companies objectively evaluate their RCA system. It’s a great way to see if they are getting the results they need from their improvement programs.
There are several ways you can do a quick check on the effectiveness of your current system:
- Repeat Incidents. Pull out last year’s incidents. Are they happening again? Are you seeing the same mistakes occurring this year? Are you seeing the same root causes as last year?
- Conduct some proactive audits. Go look for the problems you think you’ve solved. You may find that you either didn’t find the right problems in the first place, or the corrective actions just didn’t address the issues.
- Speaking of corrective actions… Take a look at the types of corrective actions you’re writing. Many companies find that most of their corrective actions ONLY address training, procedures, and discipline. Most companies find that 80% of their corrective actions fall into these 3 buckets. This indicates they’re either not finding actual root causes, or their corrective actions are weak. These corrective actions almost always target an individual or blame people, instead of understanding why smart people make mistakes.
- The absolute best way to evaluate your RCA system is to take some of those old incidents you analyzed with 5-Whys, or maybe you ran through a learning team, and run them through the TapRooT® Process. You’ll almost certainly find:
- You didn’t collect the correct information (forgot to ask questions, didn’t consider something outside your level of knowledge, etc.)
- You didn’t dig down into actual root causes. You most likely stopped at what we would consider the Causal Factor level. You probably identified a mistake or two, and then applied (blame-oriented) corrective actions directly to the mistake.
- Attend a TapRooT® Course. This will give you the chance to learn the TapRooT® Techniques, then run one of your own incidents through the process as part of your final exercise. It’s a great way to see how an advanced, easy-to-use system can produce much more effective results. View upcoming training.
Sometimes, it’s good to take a step back and re-evaluate your improvement programs. These ideas might help you do that evaluation and see whether you need to make a change.
