Root Cause Analysis: Why is RCA Important for Preventing Accidents?
What is Root Cause Analysis?
A root cause analysis (RCA) is a process for finding the ultimate source of a problem (the root cause). It goes beyond the readily apparent cause and effect to pinpoint the flaws in a process or system that contributed the issue. When defining root cause analysis, OSHA calls it a "fundamental, underlying, system-related reason why an incident occurred that identifies one or more correctable system errors."
In the world of workplace safety, a root cause analysis is for identifying, evaluating, and correcting root causes of accidents – but also of near misses and incidents that fall short of an accident.
Root cause analyses are also referred to as root cause investigations. Alternatively, since an RCA is often part of an accident or incident investigation, sometimes it's called an incident root cause analysis.
Why is Root Cause Analysis Important?
Ultimately, an RCA's meaning is to find a permanent solution for a problem.
Workplace safety is most effective when it's proactive. While an RCA is a reactive procedure in that it's triggered by something going wrong, employing a root cause analysis technique automatically broadens the scope of an incident investigation.
By systematically finding and correcting root causes, you don't just prevent a recurrence of the previous incident, but also any safety hazard that stems from those flaws. That's the importance of root cause analysis – it helps you avoid the temptation of blaming an accident on a single person or an immediate mistake.
Root Cause Analysis Techniques
There are a variety of methods you can use to pin down a list of root causes. The best root cause analysis technique for a situation varies based on the circumstances and nature of the problem.
The 5 Whys are one of the most frequently-featured root cause analysis examples – probably because it's simple, intuitive, and versatile.
Basically, being inquisitive, you just keep digging deeper by asking "Why?" to each explanation of how an incident happened. The idea is that it typically takes between 2 and 5 of those whys before you arrive at a good root cause.
Although the 5 Whys technique works for most situations, the catch is that you need an initial toehold explanation to get started. If you're truly starting with no obvious answers to how or why an incident occurred, you'll need to use the events or change root cause analysis techniques instead.
Event analysis is best for one-time incidents, rather than a pattern of troubling safety behavior. You build a detailed timeline around the target event and analyze it to see where things went wrong.
In the context of workplace safety, the change analysis technique works best to determine the root cause of a general shift in behavior. If your metrics tell you that you're having more incidents or near-misses lately, that will call for a change analysis rather than an event analysis, for example.
First, you look for all changes in the organization that proceeded the change in safety metrics. Then you define the relationship between the possible causes and effects, categorizing each organizational change as either unrelated, correlated, contributing, or root cause.
Fishbone or Ishikawa Diagram
Another example of a root cause analysis technique is a cause and effect diagram known as a fishbone diagram (for its shape) or an Ishikawa diagram (for its inventor).
If you need to brainstorm all possible causes for an incident, a fishbone diagram can help because it encourages you to think of every possible cause by examining a wide variety of aspects of the incident. Each category of potential causes forms the appearance of a rib off the spine (thus, the name).
Common categories used in a root cause analysis for workplace safety purposes include People, Environment, Management, Process, Equipment, Materials, and Measurement. The exact categories will vary. For example, some organizations prefer Personnel to People (to separate out management from the workforce). You'll also see Machine instead of Equipment and Method instead of Process.
The most important thing is that the categories are appropriate for the situation, as well as thorough.
Tips for Root Cause Analysis
There are a few things to keep in mind so that you get the most out of a root cause analysis:
- There are often multiple root causes for any one incident. Address all of them, rather than trying to narrow it down to one.
- Focus on systemic answers, not personal ones. Maybe a specific person is falling on the job but firing them won't prevent future occurrences. It's better to set up performance metrics and procedures to hold everyone accountable.
- Although brainstorming is involved, root cause analysis isn't just an intellectual exercise. You need to back up claims with evidence of a causal relationship.
- While the ultimate goal is to fix problems at the root, you shouldn't neglect the proximate problem. Fix "symptoms" of the root cause as well.
Ultimate List of Root Causes for Workplace Injuries and Illnesses
Over the years, occupational safety and health experts have found a few common patterns in the root causes of workplace injury or illness.
The root cause(s) of most incidents can ultimately be categorized as either:
- Poor management/supervision
- Company culture
- Work environment
- Improper training
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