What does Effective Root Cause Analysis Look Like?
Root Cause Analyses (RCAs) are needed in many areas of business. When it comes to safety management, they are an essential part of incident investigation, non-compliance findings, etc. By conducting RCAs and addressing root causes, employers can substantially or completely prevent the same or a similar incident from recurring.
However, many people do not really understand what this is or how to best approach RCAs.
A root cause is a fundamental, underlying, system-related reason why an incident occurred. Correcting an immediate cause may only eliminate a symptom of a problem, but not the problem itself.
5 steps of root cause analysis
RCA is not the only analytical approach, but it is one of the most simple and effective.
Define the problem.
Determine the extent of the problem.
Identify causal factors.
Identify the root cause using the 5 Y’s – ask ‘Why?’ five times.
Develop solutions to address the root cause.
Often overlooked factors in safety investigations include a lack of training about PPE, time pressures to cut corners, or even a bad culture of not thinking about safety.
Let's consider an example
Incident: a factory worker slips on a puddle of oil and falls.
A traditional investigation might conclude that the cause of the incident was “oil spilled on the factory floor” and the solution, “clean up the oil and instruct the worker to be more careful”.
However, this approach is highly ineffective.
An RCA would reveal that the oil on the floor was merely a symptom of a more systemic problem in the workplace.
When conducting the RCA, you could consider these questions:
Why was the oil on the floor?
Were there changes in conditions, processes, or the environment?
What was the source of the oil?
What tasks were underway when the oil was spilled?
Why did the oil remain on the floor?
How long had it been there?
Was the spill reported?
Here, a root cause analysis may have revealed that the root cause of the spill was a failure to have an effective machinery maintenance system, including inspection and repair, which would have prevented or detected this oil leak.
Conversely, an analysis focused only on the immediate cause – failure to clean up the oil spill – would NOT have prevented future incidents, because there was no system to prevent, identify, and correct leaks.
This case study was taken from the Occupational Safety and Health Administration (OSHA).
Benefits of RCAs
Safer workplace
Investigating with RCAs helps prevent similar events recurring. Employers reduce the risk of injury, death, and environmental damage.
Reduced costs
By using RCAs to prevent recurrence, businesses can avoid unnecessary costs from business interruption, emergency response and clean-up, audits and inspections, and fines. Regulatory fines are costly and litigation, even more expensive.
Why spend money to correct immediate causes of incidents, when they could have been prevented by identifying and correcting the underlying system management failure?
Increased revenues
Businesses that focus on prevention using RCAs are far more likely to earn public trust and attract and retain high-performing staff.
“A robust process safety program, which includes root cause analysis, can also result in more effective control of hazards, improved process reliability, increased revenues, decreased production costs, lower maintenance costs, and lower insurance premiums.”
— OSHA
At Certex, we are compliance and risk specialists. Feel free to reach out for any advice on conducting RCAs.