Safe + Sound Week

At the most basic level, a root cause is the fundamental reason—or the highest-level cause—for the occurrence of a problem, incident, or event. Getting to the root cause of any problem is important not just for resolving the issue at hand, but for identifying underlying issues to ensure that similar problems do not recur in the future. Importantly, finding the root cause should not focus on placing blame on an individual but rather on finding the systemic cause of an incident. This starts with a process called the root cause analysis (RCA).

What Is the Root Cause Analysis (RCA)?

RCA is a method of problem-solving used to identify the underlying (i.e., root) cause(s) of a problem or incident. It is a systematic process based on the basic idea that effective management requires more than merely putting out fires and treating symptoms. RCA seeks to identify and address the true, underlying concerns that contribute to a problem or event.

Why is this important? If you just treat the symptoms of the problem, that alleviates them for the short term, but it does nothing to prevent the problem from coming back again. Lasting solutions address the underlying factors—the root cause(s)— that create the problem in the first place. Targeting corrective measures at the identified root causes, subsequently, is the best way to alleviate risk and ensure that similar problems do not occur in the future.

Best Practice

The Occupational Safety and Health Administration (OSHA) encourages organizations to conduct RCA following any incident or near miss at a facility. RCA can be broken down into a simple six-step process, as outlined below.

Step 1: Identify and Clearly Describe the Problem

The first step is to understand and document the problem/issue/incident that occurred. This might involve interviewing key staff, reviewing security footage, investigating the site, etc. to get an accurate account of the issue. Safety-related incidents might require an immediate fix or prompt action before carrying out the complete RCA. This is always the priority.

Some problems are easier to define than others based on what happened and the extent of the issue. When defining and describing the problem, it is important to be as descriptive as possible, as this will aid in future steps to identify the root cause(s).

Step 2: Identify Possible Causes…Why?

There are several methods for identifying possible root causes, including the following:

• 5 Why Method simply involves asking the question “Why” enough times (i.e., five times) to get past all the symptoms of a problem and down to the underlying root cause of the issue.
• Event Analysis builds a detailed timeline around the target event and analyzes it to see where things went wrong. This method is best for one-time incidents versus a pattern of behavior.
• Change Analysis helps determine the root cause of a general shift in behavior. It looks at all changes in the organization that preceded the change in safety behavior/metrics; defines the relationship between possible causes and effects; and categorizes each organizational change as either unrelated, correlated, contributing, or root cause.
• Fishbone or Ishikawa Diagram is a visual cause-and-effect diagram that encourages you to think of every possible cause by examining a wide variety of aspects of the incident.

Step 3: Identify Root Cause(s)

Where does your questioning lead you? Is there one root cause or a series of root causes that emerge? The root cause(s) of most incidents ultimately fall under one of the following:

• Poor management/supervision
• Lack of company culture
• Insufficient work environment
• Improper training

Again, identifying the root cause should not focus on placing blame on an individual but rather on finding the systemic cause of an incident.

Step 4: Corrective and/or Preventive Action Taken

Based on the identified root causes, it then becomes possible for the facility to determine what corrective and/or prevention actions (CAPAs) can be taken to fix the problem and, just as important, prevent it from recurring in the future.

Step 5: Analyze Effectiveness

The effectiveness of whatever action is taken in step 4 needs to be evaluated to determine whether it will resolve the root cause. If not, another CAPA should be explored, implemented, and analyzed to assess its impact on the issue/problem. If it is a root cause, it should help to resolve the issue and you should move on to step 6 below.

Step 6: Update Procedures, as necessary

As CAPAs are implemented, once they prove effective, related policies and procedures must be updated to reflect any changes made. This step ensures the outcomes of the RCA will be integrated into operations and used to prevent similar incidents from happening in the future.

Benefits of RCA

Following these steps will help ensure a thorough investigation that identifies root cause(s) versus just symptoms is conducted. It further ensures that any changes related to the root cause are integrated into the organization to prevent similar events from happening again. In the end, the RCA can help:

• Reduce the risk of injury and/or death to workers and community members.
• Avoid unnecessary costs resulting from business interruption; emergency response and cleanup; increased regulation, audits, and inspections; and OSHA fines.
• Improve public trust by maintaining an incident-free record.
• More effectively control hazards, improve process reliability, increase revenues, decrease production costs, lower maintenance costs, and lower insurance premiums.