Root Cause Analysis: Obligation or Opportunity?
by Dave Righthouse – Senior Project Manager, NAES Engineering Services
Lately when kicking off Root Cause Analysis (RCA)
workshops, I’ve posed this question to the class: Is RCA an obligation or an opportunity?
Initially, ‘obligation!’ is the resounding response. However, as the workshop progresses, attendees begin to see the opportunities that a good investigation presents. By the end of our sessions, most if not all have changed their perspective.
An RCA typically yields revelations that can dramatically alter their viewpoint. But before we look at them, let’s explore their reasons for viewing it with a cumbersome sense of obligation.
First and most obvious, employees are indeed obligated to conduct an RCA when certain incidents occur in their plant. Our procedure AMP-108, ‘Accident, Incident and Injury Reporting,’ stipulates that if a facility incurs a notice of violation or other citation of non-compliance, staff are required to conduct an RCA and to produce a ‘lessons learned’ as one of the outcomes.
Secondly, if an incident creates an unsafe condition, results in an injury or produces a significant interruption in operations, our clients expect an investigation. They want causes to be identified and the risk of recurrence to be mitigated. They also look for a lessons learned and/or a best practice to emerge from the investigation. But let’s look at the opportunities that an RCA affords. For one, there’s the opportunity to learn. We can focus on processes or procedures we haven’t yet mastered. If an incident has occurred, there’s obviously something we need to fine-tune. We can explore new areas and uncover details not yet considered. Reflecting on what can be performed better naturally produces lessons learned and best practices.
There’s also the fact that when we conduct an investigation, we occupy a safe haven in which we can identify an error we’ve made, invalidate the cause and thereby effectively eliminate a string of causes. This safe space also provides us an opportunity to remove our biases, our prejudices and our subjectivity so that we can explore issues with a clear, open mind.
If we don’t partake of this opportunity, we encumber ourselves with preconceived notions, such that we can already predict the outcome. If we allow this to happen, we’re just wasting our time and energy. No wonder we end up feeling that it’s just an obligation, a box to be checked. We become almost defensive, clinging to our preconceptions. In this brain fog, it’s almost impossible to arrive at effective, innovative solutions.
If we let our guard down and free ourselves from subjective biases, it opens us to those ‘aha’ moments of ‘I never would have thought of that.’ New ideas come crowding in like iron filings drawn to a magnet.
It’s enlightening to explore a decision that was made totally in good faith at the time of execution but which has now become the center of controversy. What information had the subject received – or not received – that prompted that decision? What can be done to make the next such decision well-founded and less risky? When viewed from this perspective, the opportunities seem nearly endless.
RCA investigations routinely produce benefits and growth areas that we weren’t expecting. When the solutions that emerge from them focus on mitigating a possible recurrence, detecting when elements are forming that could lead to another incident, or even reducing the impact of a recurrence, we all gain from them.
When we make identifying lessons learned and implementing best practices the primary objectives of an investigation, the opportunities become clearer. A good investigation goes well beyond the obvious – and here is where the real opportunities lie. This is where we find the issues that influence human error, the precursors of mistakes and missteps. If we can eliminate or raise our awareness of them, we can achieve safer and more productive workplaces.
In my experience, people who view an RCA strictly as an obligation often ask the question ‘When is enough enough?’ In other words, when has the analysis gone far enough to reach conclusive findings? Those who consider this work an opportunity, on the other hand, continue the effort until they feel that they’ve extracted every chance for improvement from an incident. They rehash each element to ensure that they’ve left no stone unturned, no detail unexamined.
For many, the distinction between an obligation and an opportunity comes down to this: an obligation is an external force, one that compels us to fulfill another party’s requirement — whereas an opportunity in their view is motivated internally and therefore piques their curiosity. Seen in that light, an RCA becomes a labor of love that encourages reflection and learning.
I could easily construe writing this column as an obligation. But in fact, I’m grateful for the opportunity it provides to share my insights with others. I enjoy trying to make things better – especially if it involves ferreting out lessons learned and best practices. My thanks go out to those people who have made a practice of extracting the opportunities that life puts in front of them. I look forward to crossing paths with you at our next…opportunity.
We have two RCA workshops scheduled for the near future: July 18-20 in Deming, N. M., hosted by Luna and Lordsburg; and August 8-10 in Jenks, Okla., hosted by Green Country Energy. As always, if you need RCA assistance or would like to schedule a workshop, email me or Engineering Services Director Brian Beatty.
