The BEST Root Cause Analysis Performance Indicator
What is the BEST Root Cause Analysis Performance Indicator?
If the root cause analysis and corrective actions for an incident are effective, they will prevent a repeat incident (or even repeat Causal Factors) from happening.
Thus, monitoring for repeat incidents (or repeat Causal Factors) is probably the best way to see if your root cause analysis is effective.
What is a Repeat Incident?
The first question you need to answer is:
What is a repeat incident?
How “identical” does it need to be?
Judging repeat incidents takes some soul searching. The real question is, should have the previous incident investigation prevented the current incident.
Here are two examples:
- Should the investigation and corrective actions for the Challenger Space Shuttle accident have prevented the Columbia Space Shuttle accident?
- Should the BP Texas City fire and explosion accident investigation have prevented the BP Deepwater Horizon accident?
Neither of these are “identical” to the previous accident. But corrective actions for the Generic Causes of both accidents should have prevented the subsequent accidents. So, in my opinion, they were repeat incidents/accidents. Plus, all four accidents had precursor incidents that were more closely related. Therefore, all of these repeat accidents indicate a problem with the previous incident investigations.
What is the rate of repeat incidents/accidents for your company? Do you have 50% repeats? 10%? 0.1%?
Each repeat incident provides a learning opportunity to improve your incident investigation, root cause analysis, corrective action, and incident review processes. Are you using these opportunities to improve your system?
You will have to be the judge of how close an incident is to be counted as a repeat incident. The key question is, should have the fixes for previous incidents prevent the repeat incident.
What Problems Could a Repeat Incident Indicate?
There are at least three likely problems if you have a repeat incident:
- A problem with your root cause analysis.
- A problem with your corrective actions.
- A problem implementing your corrective actions.
Problems one and two also indicate a problem with your incident investigation review process.
Problem three indicates a problem with your management of corrective action implementation.
Note that if you are using TapRooT® Root Cause Analysis, it will help you identify all three of the problems indicated above.
Don’t Let Incidents Repeat!
1. Use effective root cause analysis (TapRooT® RCA) for all your precursor incidents and serious accidents.
2. Use the Corrective Action Helper® Guide/Module and the Hierarchy of Controls that we teach in TapRooT® Courses to make your corrective actions effective.
3. Track the implementation and effectiveness of your corrective actions to manage your corrective action process.
That’s how to avoid repeat incidents.
To find out more about TapRooT® Root Cause Analysis Training, CLICK HERE.
