Root Cause Analysis for Safety and Health Solutions

No activity in Safety and Health management holds more potential for solving problems, reducing losses, preventing injuries, and transforming an organisation from a traditional, reactive one to a progressive, proactive one than incident investigation. Unfortunately, that potential is lost in many organisations because investigations are conducted in such a way that they actually promote a reactive approach rather than a pro-active preventive approach. When investigations are conducted as finger-pointing, blame-fixing, witch-hunting interrogations, as they all too often are, it sends a message loud and clear to employees that their organisation would rather find a scapegoat for that particular incident and be done with it than to take the extra time and effort required to ensure that the incident does not happen again.

Why Root Cause Analysis

If an unwanted situation manifests itself in an organization that results in the unproductive consumption of valuable resources and it starts to occur in a more frequent manner then it becomes necessary to understand what the real contributing factors to this situation is. This would be the starting point to eliminate these factors in an attempt to prevent the situation from occurring again. This method is generally referred to as the Root Cause Analysis. The purpose of the approach is to find the real or root causes that result in the unwanted consequences and then developing preventative and control measures rather than instituting measures that will only address the symptoms.

The root cause analysis, sometimes called the root cause failure analysis is one of the more modern types of accident investigation systems. The procedure consists of a set of processes through which the underlying causes of adverse outcomes may be identified. The goal of the investigation is preventing the re-occurrence of such events.

The Process of Root Cause AnalysisThere are many different processes by which root cause analyses can be performed and the engineering and industrial risk management literature is rife with arguments for and against the different approaches. It is not the purpose of this research to explore those differences.

Root Cause Analysis is designed to systematically evaluate the possible ways that a loss (or series of losses) could have occurred. During the process the investigator collects and arranges factors in such a way as to rule out possibilities and develop a technically feasible loss scenario. The investigator should identify the key causal factors and fundamental contributing factors of the loss scenario. In conclusion the investigator should also produce recommendations to correct the fundamental contributing factors, thus preventing the recurring loss and similar future losses from common contributing factors. This approach may seen to be sufficient to prevent future accidents, but unfortunately the methodology focuses only on a singe cause-effect outcome.

Once the root causes have been established management must decide whether the cost to mitigate it will be beneficial or whether to just continue to treat the consequences. This is often not a strait forward decision. It may be quite easy to approximate the cost of the mitigation measures it is usually a complex task to establish the cost of treating the consequences.

One area of undisputed agreement is the observation that without strong support by upper management, root cause analyses will be performed in a mechanical manner, with the singular purpose of meeting regulatory requirements.

Root Cause Analysis Conclusion

Most real-world events do not follow a simple cause-effect trail. A single factor may have multiple consequences. A combination of factors may bring about a single result, or they may initiate multiple effects. Causes can themselves have causes, and effects can have subsequent downstream effects. The failure mode should also be considered in all of these models.

© Carl Marx 2009