082: SMS Part 3 - What is Root Cause Analysis (RCA)?

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As mentioned in episode 81 - What is "Systems Thinking," I will talk about root cause analysis or RCA - another aspect of a systems approach, Let’s define it and talk about how it can be applied.

In episode 33: Lean Safety, I recommended some excellent books to help you out. TapRoot® is another great resource as well as the book Pre-Accident Investigation by Todd Conklin - I have this one and contains great insight. But remember, whatever books you read or concepts you follow, if all you get is a strategic overview of these principals, then you will need to follow that up with tactical training to be able to use the right tools and techniques for a given situation. For example, I went through HOP training, was a H.O.P. coach for a former employer, so jump on Linkedin and ask your network how they are applying these concepts, ask for help.

One thing I want to share about Conklin’s book that has stuck with me (there is a lot, but this one is a favorite); “Safety is not the absence of events; it is the presence of defenses.”So true!

So Let’s get into a definition of RCA. First, I want to reference TapRoot® . Over 30 years ago, they started with research into human performance and the best incident investigation and root cause analysis systems available. They put this knowledge to use to build a systematic investigation process with a coherent investigation philosophy. Then, they used and refined the system in the field. In 1991, they wrote the first TapRoot® Manual that put all of this experience together into an incident investigation system called TapRoot® .

According to TapRoot® , a definition of Root Cause Analysis is as follows: “The systematic process of finding the knowledge or best practice needed to prevent a problem.“ What root cause analysis tools or methods should you use? Here is guidance to help you pick the root cause analysis system you should use:

• You need to understand what happened. Because you can’t understand WHY an incident occurred if you don’t understand HOW it happened, and before that, you need to know what happened.
• You need to identify the multiple Causal Factors (this is the HOW) that caused the problem (the incident). Your root cause analysis system should have tools to help you identify these points that will be the start of finding root causes.
• You will need to dig deeper and find each of the Causal Factor’s root causes. These are the causes of human performance and equipment reliability issues. TapRoot, with many years of experience, has found that investigators (even experienced investigators) need guidance – an expert system – to help them consistently identify the root causes of human performance and equipment reliability issues. This guidance should be part of the root cause analysis system. Plus, the root cause analysis tool must find fixable causes of human error without placing blame. Blame is a major cause of failed root cause analysis .
• If this is a major issue, you should go beyond the specific root causes of this particular incident. For major investigations, you should look one level deeper for the Generic (systemic) Cause of each root cause. Not every root cause will have a Generic Cause. But, if you can identify the Generic Cause of a root cause, you may be able to develop corrective action that will eliminate a whole class of problems. Thus, your systematic process should guide you to find Generic Causes for major investigations.
• Root cause analysis is useless if you don’t develop effective corrective actions (fixes) that will prevent repeat incidents. TapRoot has seen that investigators may not be able to develop effective fixes for problems they haven’t seen fixed before. Therefore, your root cause analysis system should have guidance for developing effective fixes.
• Finally, you will need to get management approval to make the changes (the fixes) to prevent repeat problems. Thus, your root cause analysis system should include tools to effectively present what you have found and the corrective actions to management so they can approve the resources needed to make the changes happen.
Another take on this is that RCA involves investigating the patterns of adverse effects, finding hidden flaws in the system, and discovering specific actions that could have contributed directly and indirectly to the problem. Which often means that RCA reveals more than one root cause. And thus the title lends itself to criticism by some folks - it implies one root cause when we know that isn’t the intent. I call these folks word nerds, and these are the Gurus I refer to when I point this out - not the ones I mentioned earlier that understand this. They take the literal meaning instead of using their brains a little and understanding that it is just a catchphrase, and the purpose or spirit of the phrase is what is essential.

The second example of an or