Apparent Cause Evaluation (ACE) or “Almost Care Enough”
This is a terrible tool that nobody should use, the Apparent Cause Evaluation.
Everything about Apparent Cause Analysis sounds as though some executive wanted a whitewashed name for coercing his investigators into submitting a half-baked investigation. Cookies half-baked are wonderful; incomplete investigations allow repeat death. What is it people say about hope as a strategy?
The worst of all worlds. At least 5-Whys practitioners understand that it’s completely subjective, biased, miserable to apply, and not reproducible across teams.
The ideology behind Apparent Cause Analysis as an acceptable alternative to Root Cause Analysis is 1-for-1, exactly, “It could never happen to us” mentality perfectly blended with hypocritical denial of your “Safety First” slogan
Here’s the reality that ACE thinking enables:
OPS Director: I don’t have time to fix the equipment; I have to run the equipment!
Site Manager: I don’t have time to find root causes; I have to get people back to work on the production floor that just killed a man!
CEO: I don’t have time to learn what happened; I have to tell the press what happened and how I’m going to fix it!
Which one sounds more like how the world works — “Safety First,” or Mike Rowe’s “Safety Third”?
Another disturbing concept: some ACE programs require corrective actions should “not be programmatic in nature.” In other words, we only want to look for who to punish, what mistakes were made, easy fixes, and we DEFINITELY don’t want to consider improving the way we do business. If you don’t run near-misses and minor incidents fully to ground, unplanned outages and fatalities will continue.
Heinrich’s Pyramid tells us that the root causes that allowed a SIF are the same ones that caused the PSIFs and non-injuries.
Correcting a root cause prevents severe accidents. Correcting an apparent cause makes a nice bullet point for your psychological safety program and leaves the real vulnerabilities out on the jobsite.
“If you don’t have time to do it right the first time, you don’t have time to do it again.” Alternately, if you didn’t have time to prevent the first death, hopefully you’ll make time to prevent the second. Doubtful.
ACE/ACA is a tool for leaders that don’t care enough about their operations or people to prevent the incident from happening again.
If it’s not worth an RCA, it’s not severe enough to investigate at all.
Proper Root Cause Analysis takes the necessary time to determine what allows SIFs, PSIFs, and near misses. TapRooT® RCA structures this process into a repeatable, standardized, objective system that operationalizes trite ACE guidance to only use the evidence.
Oh, and a TapRooT® RCA for a single causal factor should take about 15-20 minutes. We have been using algorithms for solving human performance and equipment problems long before the world lost its mind over AI and machine learning.
For learning TapRooT® RCA to use for minor incidents, enroll (or enroll your team) in a 2-Day course.
Sign up for the 5-Day, Advanced TapRooT® Root Cause Analysis Team Leader Training if you’re in the business of preventing PSIFS and SIFS. Here’s the link for current 5-Day TapRooT® courses.
Register your team(s) for the course(s) that meets your needs: https://store.taproot.com/courses
Look me up on LinkedIn if you want to see more, and stay real.
Graphic source/credit: Cafe Hayek, “Then a Miracle Occurs,” Don Boudreaux, March 2014.