Thank you to Brendan O’Donnell from DQS for this in-depth look at all the issues around Root Cause Analysis.
Incidents and non-conformities happen. How we respond will determine whether the incidents or non-conformities happen again. Often without any systematic analysis, we charge ahead with hastily-conceived, ill-considered solutions that merely sweep the incidents or non-conformities under the carpet, to be inadvertently revealed at some later date… potentially in some much worse incarnation. What we need is a method that helps us find the core issues.
We form organizations to get work done. As the work we want to do become larger and more complex, so do our organizations. At some point, we move beyond the capability to function without extensive, potentially complicated processes and systems.
These require management. However, we are human and we make mistakes – many. Management systems are not always perfect and so is our ability to manage them. We cannot predict the future with any accuracy, and we are unable to see all the potential ramifications of the actions we take. Mistakes occur.
For sustained effectiveness of a management system, organizations should have a system for identifying, reporting and investigating actual and potential incidents/nonconformities and other related losses. No activity holds more potential for solving problems, reducing losses, preventing incidents/nonconformities, and transforming an organisation from a traditional, reactive one to a progressive, proactive one than a well applied incident/nonconformity investigation process.
Unfortunately, that potential is lost in many organizations because investigations are conducted in such a way that they actually promote a reactive approach rather than 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/nonconformity and be done with it than to take the extra time and effort required to ensure that the incident/nonconformity does not happen again.
This article does not differentiate between investigating an incident or nonconformity in any standard. If we are to determine causes, the focus should ultimately be on root causes and this requires that a root cause analysis investigation system and methodology needs to be established, implemented and maintained. Root cause analysis (RCA) is a methodology for finding and correcting the most important reasons for performance problems. It differs from troubleshooting and problem-solving in that these disciplines typically seek solutions to specific difficulties, whereas RCA is directed at underlying issues.
As a business process improvement tool, RCA seeks out unnecessary constraints as well as inadequate controls.
In QHSE, it looks for both unrecognized hazards/aspects and broken or missing barriers.
It helps target corrective action and preventive action efforts at the points of most leverage. RCA is an essential ingredient in pointing organizational change efforts in the right direction.
Finally, it is probably the only way to find the core issues contributing to your toughest problems.
While it is often used in environments where there is potential for critical or catastrophic consequences, this is by no means a requirement. It can be employed in almost any situation where there is a gap between actual and desired performance. Furthermore, RCA provides critical info on what to change and how to change it, within systems or business processes.
Significant industries use root cause analysis, examples include manufacturing, mining, construction, healthcare, transportation, chemical, petroleum, and power generation. The possible fields of application include operations, project management, quality control, health and safety, business process improvement, change management, and many others..
This point of root cause analysis — to dig below the symptoms and find the fundamental, underlying decisions and contradictions that led to the undesired consequences. If you want your problems to go away, your best option is to kill them at the root.
A proactive approach is essential. This approach, while taking some time, is the only approach to take if an organisation wants to be proactive and preventive in QHSE management and wants its employees to understand that. And in the long run, this approach will actually save time, money, in preventing those incidents/nonconformities which have been preceded by similar potential incidents/nonconformities.
A documented, systematic RCA methodology should be established to assist investigators and the organization to analyze evidence and information gathered to ensure the identification of immediate causes, root causes and system deficiencies. A systematic RCA methodology will ensure a consistent approach throughout the organization. Competence and awareness in the adopted RCA methodology is paramount to ensuring a successful investigation process. Organizations should be able to provide evidence of personnel who have been assessed for competence in the use of the adopted methodology. Managers and supervisors need to have the knowledge and skills to apply the adopted methodology.
In one way or another, all the various management tools and methods that have been developed over the years are about improving how we manage ourselves, our processes, and our systems. We want productivity, we want quality, we want reliability, and we want safety. We want these things now, and in the future. In fact, we want these things to get better over time. This is called continual improvement.
Root cause analysis is a process of continual improvement. It is not a pre-defined set of tools and methods, and it is not a flash in the pan management fad. It recognizes that we are going to experience problems, because that is an unavoidable aspect of being human. It is a guiding philosophy that says “find the real, important reasons for our problems, understand why they exist, and change the conditions that create them!” There are many different versions of root cause analysis in existence, and the differences between them are not always cosmetic. However, there is a general philosophy that is shared universally amongst successful organizations: root causes exist, and they can be found (and uniquely identified) through careful, evidence-based investigation and thoughtful analysis.
Finding and identifying root causes during an investigation adds significant value by pointing out significant, underlying, fundamental conditions that increase the risk of adverse consequences. Targeting corrective measures at the identified root causes is the best way to ensure that similar problems do not occur in the future.
References: DQS E-learning platform; IRCA Global’s RCAT® Methodology
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