In a perfect world there would be no errors and a company’s operations would be under complete control at all times. There would be no unplanned, undesirable events. No accidents, incidents or inefficiencies would result in financial loss to the company. Unfortunately, such perfect control does not exist in any company we know of. So where do we look for answers when costly, painful, and sometimes tragic accidents happen?
ROOT CAUSES ARE FAILURES OF THE SYSTEM, NOT OF INDIVIDUALS We all know that neither people nor management systems are ever perfect. Organizations nevertheless depend upon supervisors and managers to eliminate or control undesirable events. When these events do occur, since they were not prevented by policy or practice, something has failed in the management process. These are root failures of the “system.” Studies have shown that approximately 94 percent of errors in an organization are due to these systemic failures. If so, it follows that accidents and injuries are caused by operational errors, not by failures of individuals. It is management’s responsibility to identify and correct these errors—not that of individual workers who have no control over the company’s operating policies.
PLACING BLAME FOR ACCIDENTS WILL NOT PREVENT RECURRENCE This is a significant issue because in most companies, instead of looking for the cause of undesirable events, the “system” typically looks for someone to blame. Some of you may have experienced the negative cycle that can be created during an accident investigation. Despite the best of intentions, an incident investigation sometimes turns into a witch hunt. The true objective—to improve performance by fixing the problem—becomes secondary to figuring out who is to blame. This emphasis invariably leads to a downward spiral, involving blame, then punishment, then more blaming and more punishment. As a result, when the next incident happens, no one is willing to talk. Some call this the “Bart Simpson Syndrome.” You know you have it when the response to a question is: “I didn’t do it, nobody saw me do it, you can’t prove I did it,” or “I don’t know anything about it.” Root Cause Analysis is essentially a tool for eliminating or preventing the finger-pointing and blaming. If you don’t take time to identify all the contributing factors to an accident, you’ll miss critical information about the underlying system. Then the common action plan is to punish the worker that had the accident and remind everyone else to “be more careful next time.” Without root cause analysis, you have not significantly reduced the potential for similar incidents in the future. Blaming individuals almost always results in defensive behavior, resentment, closed communication, and disciplinary problems. It seldom prevents recurrence of an incident because it changes nothing about the system underlying the incident. Corrective action should first be sought through the improvement of systems and processes, not through placing blame.
FOCUS ON HOW THINGS ARE DONE IN THE OPERATION Assuming for a moment that no one makes a mistake on purpose, it follows that learning why the mistake occurred is far more important than deciding who made it. It is more meaningful to focus on the way things are done on the job, than on the individuals involved. Corrective action should first be sought through the improvement of systems and processes, not through placing blame. Careful unbiased analysis is the key to locating and identifying system errors. Unplanned and undesired events stem from acts and decisions–or from failures to act or decide–which the management system permits. Once detected and understood, such events can be changed or eliminated in most cases.
ACCIDENTS ARE SYMPTOMS, NOT CAUSES A recent review of a company’s accidents revealed that most of the investigations listed “human error” as the cause of the incident. Unfortunately, this is often where accident analysis ends. A basic failure of most investigations is that they identify and correct only the immediate causes, or symptoms, of an accident. The real causes of a disease are not the symptoms that are readily apparent, but some underlying malfunction that must be corrected to eliminate the symptoms. Most of us will agree that, whether it’s an accident or an illness, treating a symptom seldom works. Too often we warn someone who was injured to “be more careful next time” instead of identifying and correcting the real cause of the problem. This short term fix is quick and easy, but in the long run serves no useful purpose. New problems are created if we fail to see inadequacies in the operating process that lets accidents happen in the first place. The identification of root causes is the key to problem solving and continual improvement. The theory of root cause analysis is a very simple, effective method for understanding problems in a safety system. The application of this theory and method is the foundation for any constructive accident investigation.
THE TRUE PURPOSE OF INVESTIGATIONS IS TO PREVENT RECURRENCE It is important that you keep this purpose in mind. Doing so can improve the system instead of just blaming the worker. You must determine what needs to be changed and how. This requires collecting and analyzing all the facts surrounding the incident before presuming what caused it to happen.
WHO SHOULD BE INVOLVED IN THE ANALYSIS? The best and most appropriate people should be selected to investigate an accident, both for obtaining accurate facts and for increasing safety awareness. At a minimum, the person who was involved in the accident, an employee who understands the work process involved, and the immediate supervisor should search for facts. For serious accidents or near misses, a team of key personnel including managers and members of the safety committee should jointly conduct a follow-up investigation.
SEARCHING FOR ROOT CAUSES Root cause analysis is not a difficult concept to learn or understand. An accident occurrence is simply a breakdown somewhere in the system. Any system is a network of interrelated elements of which people are only one part. Through root cause analysis, investigators examine the cause and effect chain of events that led to the accident. The effect is the accident. Working backwards in the system, starting from the incident, all possible contributing causes are considered— the environment, training, procedures, equipment, and human behavior. In most cases, you will find that accidents are caused by multiple underlying causes, each of which must be identified and corrected in order to prevent a recurrence. Once all possible causes are identified, each one is examined by studying the cause and effect chain until the root cause is identified. This is accomplished through a simple questioning process. For example, it is not enough to learn that an injury occurred because an employee didn’t follow a particular procedure. It is critical to find out why he chose not to follow it. Was he in a hurry? If so, why was he in a hurry? Was there a production push? Was there a shortage of personnel? Was there a communication breakdown with the supervisor? Was the employee properly trained? Was the necessary protective equipment available? You will get honest answers to these questions only if management has reduced employee fear of repercussion and developed an atmosphere of trust in the company. Employees must know that the goal of accident investigation is prevention, not blame. Through this questioning process, you can discover aspects of the system that, when improved, can accomplish this.
GROUNDWORK FOR ACTION The root cause or causes are the most basic underlying factors which, if corrected or removed, will prevent recurrence of the situation. It important to know where to look for root causes. In nature, roots are found in the soil. In organizations, the soil is the system that management uses to plan, lead, organize, and control. Usually, these are published as the policies and procedures of the organization. Hopefully, those written policies will be carried out by the entire workforce. If not, a root cause analysis will be appropriate.
DIG DEEP FOR ANSWERS In your search for the root cause, each answer to the question “Why?” must either lead toward or yield the root cause. No analysis should lead to a dead end. If it does, something must have been missed, or perhaps an alternate path to the answer exists. You have not found a root cause until you have reached a point where you can take root action. To be successful in root cause analysis, you must ask and answer the question “Why?” at least five times. Each question should dig deeper for underlying, contributing factors that may be in need of correction. We hope the worksheets that follow in this issue will help you track incidents back through the cause and effect chain of operation until you identify (and ultimately eliminate) all possible causes of personal pain and financial loss.