Last week we wrote about risk management and risk assessment. If you’ve had an incident though, you need to know about root cause analysis as it is critical in a safety system designed to remove risk from your operations, including a transport operation.
So, you’ve had an incident in the workplace and the very first step is to ensure everyone is OK and to ensure that people who need help, get it! The first question you need to ask in any situation involving people is around making sure people are OK, first and foremost. Anything else is not important.
assessment. If you’ve had an incident though, you need to know about root cause analysis as it is critical in a safety system designed to remove risk from your operations, including a transport operation.
So, you’ve had an incident in the workplace and the very first step is to ensure everyone is OK and to ensure that people who need help, get it! The first question you need to ask in any situation involving people is around making sure people are OK, first and foremost. Anything else is not important.
Once that happens though, the work begins. Its not an easy task to work through, but every incident, big or small needs to be investigated. So now it’s time to pull out your inner Sleuth and get down to working out what exactly happened and how can we prevent it from happening again.
In a nutshell, getting to the root cause has 5 simple steps, the steps in themselves are not always easy, but the overarching process isn’t too hard to grasp. So here we go….
1. Write down the problem or describe the event you need to prevent.
You had an incident and many things may have happened, but you need to work through each one in a RCA (root cause analysis) one by one. So let’s start from the beginning of the issue, the first problem that occurred. Write this down in some detail, no more than a paragraph.
2. Now it’s time to ask yourself or better the team working through this RCA, “Why does the problem occur?”
Look for old events or ask staff through an interview process if they have seen or felt this has occurred in the past. You’d be amazed at how often things happen but go unreported. Have a look at the timeline, gather in qualitative and quantitative data to add to the question as it may have occurred due to a specific element such as time of day or due to being rushed. My point is, really step into why or how this event occurred, in your view.
3. Ensure you write down the answer or multiple answers on paper.
It’s important to record all your findings. You may want to reconvene later or simply want to take a break and there may be much conjecture if this is being fleshed out in a team environment, so you don’t want to lose any important element, you may even need the notes if the incident occurs again to go through a further RCA.
It’s also important to be able to show that you have conducted an RCA potentially at a later date or court case even, so it’s wise to document your meeting minutes.
4. You now have your root cause or hopefully even better, a bunch of root causes as to how or why an incident has occurred.
You now need to establish the final root cause(s) of the incidents and to do that you need to ask yourself or the team (It’s much better to do this in a team), why each root cause is in fact the root cause of the incident. The best way to do this is to ask ‘WHY’. “Why is this the root cause?”
You cannot ask why enough during a root cause analysis, keep asking until you get to an end point in the thought process.
“Why” is taken to mean “What were the factors that directly resulted in the incident?” What was the effect of the factors involved?
Here you can also classify the why into two categories, casual factors that relate to the incident in the sequence or root causes that interrupted the steps of the process chain when removed.
5. Continue to hash out the incident through the root cause analysis until you are satisfied that you have reached the root cause of the issue.
You also need to identify all other harmful elements that have equal or better claim to be the root cause. Often you will have multiple root causes and it is important to hash these out to ascertain the most optimum root cause.
Once this step has been completed you are free to move onto exploring corrective actions, to see if, with a high degree of certainty, it will prevent an incident such as this from occurring again.
A great question to ask is; if this was implemented before the incident, would it have significantly reduced the likelihood or better, prevented the incident from occurring in the first instance?
There is no certainty that with an RCA process an event will be removed from occurring again. A check in and visual inspection of the improved process should be conducted, but you never will know if what you have implemented is rock solid. The only way to try and improve from this point is to complete a risk analysis of the new process and with a fresh set of eyes to determine if someone else foresees a risk to the process.
No one is perfect, but together we can create a safer environment.
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