Definition – Root Cause Analysis (RCA)
Root Cause Analysis is a process to enable the user to readily identify the root causes of an incident/accident. It is a useful process for understanding and solving a problem. Figure out what negative events are occurring. Then, look at the complex systems around those problems, and identify key points of failure. Finally, determine solutions to address those key points, or root causes.
The following guidance is intended for you to be able to complete Root Cause Analysis on any accident or incident you may experience in your workplace and prevent reoccurrence.
Following this guidance should also enable you to remove individual blame from the incident/accident as it focuses on the reasons why actions or behaviours occurred rather than individual failings.
The purpose is to provide a swift and effective way to prevent incident/accident recurrence which can potentially be extremely damaging to a business and its employees. It can also provide a great support focussing attention away from individual blame or equipment failure and re-direct focus onto how the safety management system “allowed” these deficiencies to exist.
If used well it can provide an extremely useful method of learning from incidents/accidents and ensuring employees and the business are better protected in the future.
Application of Root Cause Analysis
It is a systematic process which can form part of an incident/accident investigation and which focuses on 3 main aspects:
- Immediate Causes
- Underlying Causes
- Root Causes
All 3 stages of the analysis are important to build up a picture of how and why the incident/accident occurred and what can be done to prevent recurrence.
These are aspects of the incident/accident which directly influenced the outcome (damage or injury) and are often referred to as “direct causes”. They are the features of an incident/accident which immediately contributed to harm or damage being caused.
Example – if an employee is injured by items falling off shelving, the items falling and striking the employee is an immediate cause.
These aspects of the incident/accident are effectively contributory breaches which in themselves did not cause harm but made a significant contribution to the incident/accident.
Example – poor maintenance of the shelving could be an underlying cause.
It is generally when identifying underlying causes you may discover more than one reason why a problem exists. In the example above this could be a faulty shelf or incorrect stacking of materials.
These are effectively the purpose we are doing Root Cause Analysis to discover the root cause of our incident/accident. Generally these are aspects of our safety management performance which have in some way failed. You may have identified in Immediate and Underlying causes that there have been individual, equipment or structural failings which directly or indirectly contributed to the incident/accident.
Example – the failure to supervise the shelving/racking maintenance programme is a root cause
By addressing root cause you effectively remove the key reason why the events were allowed to develop for the incident/accident to occur. By only addressing Immediate and Underlying causes you allow the fundamental management deficiencies to remain and therefore make recurrence more likely.
Solution and Preventing Recurrence:
In the above example, as a solution, effective measures are taken to ensure that the racks are properly maintained. The faulty shelves are repaired. This prevents future recurrence.
Summarising the Application of Root Cause Analysis
In general, RCA uses an ordered process as follows:
- A problem, issue or challenge is carefully defined or described in the most factual terms (gathering data and evidence about the incident in question (such as where, when, how, who etc.).
- Data and evidence is clustered and/or classified to create a timeline of events that led to an incident or accidents. For every behavior, condition, action, and inaction specified in the “timeline” the question can be asked what should have been done compared to what was actually done.
- The “why” question is asked multiple times to help identify the causes that may have contributed to the incident (going to deeper causes each time the question is asked).
- Possible solutions are identified, based on the root cause analysis that, when effective, would be likely to prevent recurrence with reasonable certainty, are within the organization’s control and do not cause or introduce other new, unforeseen problems.
- Once root cause(s) have been identified, and possible solutions have been evaluated, corrective action or change can be planned to help prevent recurrence of the incident.