Fixing “THE” Root Cause
One basic human mistake was part of an explosion at an oil and gas refinery.
What is the root cause of this mistake?
If you have an answer, GCE.
GCE? The US nuclear navy exam-grading annotation has a wonderful term: gross conceptual error (GCE). Even experienced problem-solving experts search for the simplistic silver bullet “root cause”.
Root causes are always plural.
Missing best practices led to this “simple” human error, so we need to understand the “what” before the “what allowed.” After basic interviews and a site visit, we may have found these conditions:
Those details are important, especially for preventing a repeat mistake. Simply writing down the “what” lets us find root causes.
TapRooT®’s Root Cause Tree® and Dictionary (never the two shall part) use the evidence above to direct us to six objective root causes using the evidence collected above.
Do you see why discussing “the root cause” gets a GCE? Even a simple human mistake of “lefty-tighty” had many missing best practices as precursors. Human error is the start of a proper RCA investigation, not the end.
For the curious, this explosion resulted from 23 root causes spread across the six causal factors here:
Four root causes appeared multiple times in this investigation, requiring generic cause analysis. Five other root causes also led to generic causes for a total of nine systemic issues.
Identifying root causes is not difficult, but it DOES require structure, discipline, and a thorough process if you want to find every root cause in a timely manner.
A 5-Day TapRooT® Root Cause Analysis Team Leader course equips your investigators with the skills and structure to perform a complex investigation like this refinery explosion, fatalities, and SIFs, auditing and proactive investigation, equipment troubleshooting, and analysis. These tools are set in a framework for problem-solving based on the discipline of human performance improvement.
The next time you hear someone talk about “THE” root cause, do a v8 head bonk, “should have done a TapRooT® Investigation!” Then go do the investigation.
