Sustainability in Business

 

The importance of Root Cause Analysis

Root cause analysis is a critical activity to help organizations to prevent recurrence of incidents. It saves the organization time and money in the long run. It forms part of the concept of risk-based-thinking as required in all the new generation management system standards.

Root cause analysis is a process designed for use in investigating and categorizing the root or basic causes of events with safety and health, environmental, quality, reliability and production impacts.

The event is an incident, which is any occurrence which is undesirable. It could or does result in harm to the environment, persons or property, although not always. More will be said about this later.

We do root cause analysis because, seldom, if ever, will we find that the most apparent causes for the incident are the real causes.

Several techniques are available to enable us to properly investigate incidents and find the root causes. In future I will discuss some of the popular techniques which are available.

1.       Purpose of finding root causes

The main objective of root cause analysis is to find the real causes of the incidents, and then to remove them so that the incident will not occur again.

We need to not only find out what happened and how it happened, but also why it happened. If we know why it happened, suitable corrective measures can be implemented to prevent recurrence of the incident in future.

We investigate so that we are able to understand why the incident took place, because only then can we develop recommendations for corrective action (corrective action is removing the cause of nonconformity to prevent it from happening again).

2.       Old theory vs. new theory

The old way of thinking was that incidents are caused because workers choose to work in a substandard or ‘at-risk-behavioural’ manner. The blame was placed squarely on the worker, with no consideration for possible outside forces which could have influenced the workers. The thinking was that workers make errors, and that they lack what is known as “common sense”. The employee is the problem!

In this way of thinking, to prevent incidents the worker must work more carefully and pay more attention to their work.

This way of reasoning creates a ‘blame-fixing’ culture in the work place. We want to know who caused the incident, rather than what caused it. The result is that our corrective actions are inefficient and ineffective.

The new theory takes into consideration the dynamics of systems that interact within the overall risk control management system.

The reasoning is that incidents are the result of defects in the system. People are only a small part of the overall system.

Incidents are most of the time not caused by one single cause. When we investigate incidents we need to uncover the basic or root causes in the system. To prevent incidents, the system must work better.

This approach leads to long-term solutions. If we achieve long-term results, we are preventing things from going wrong, and are taking control of the business.

We need to understand clearly what an incident is before we will be able to achieve this. An incident is an unplanned event, which could or does result in harm to people, the environment, processes and property.

An incident which results in harm is called an accident.

If there is no detectable harm resulting from the incident, we call it a near-miss.

Both accidents and near-misses must be reported and investigated to determine its root causes. A near-miss is an early warning of an accident that will happen. Removing the causes before we have a real accident will thus benefit the organization. Near-misses should be investigated as if they were accidents.

An accident can be illustrated as follows:

A tanker carrying pesticide was travelling at a speed of 80km/h. It attempted to overtake a minibus with 6 passengers towing a boat. The 2 vehicles collided. 5000L pesticide was spilled, 3 people were seriously injured and the minibus and the boat were completely destroyed.

A near-miss can be illustrated as follows:

A waste water treatment plant partially failed. When monitoring the waste water streams to determine the impact of the partial failure, it was discovered that the pH of the effluent stream increased, but did not exceed the permitted levels.

3.       Types of incidents to investigate

All incidents, be they near-misses or accidents, must be reported and evaluated to determine the actual or potential losses. Those near-misses with high potential for losses to people, materials, the environment or processes must be investigated thoroughly as if the losses actually occurred. All accidents must be investigated.

Take note of the fact that, for example, nonconformances in production or service delivery are also classified as incidents that need to be investigated to fine root causes to prevent recurrence (corrective action). If, for example, process performance deteriorates, even if nonconformances were not yet observed, are also incidents, and must be investigates to find root causes (preventive action). Thus, incidents under the quality management systems are not excluded from root cause analysis.

The degree of investigation will depend on the degree of harm or possible harm. The amount of time spent on the investigation will be dependent on the degree of harm or possible harm, and the complexity.

I will post more information regarding this topic in future.

Please feel free to contact me at koosgouws10@gmail.com. And you can visit our website at www.sheqmanagementsystem.co.za.