Can Being Cheap on RCA Cost Your Company Big Bucks? … Let Me Count the Ways!
Cheap Can Cost You…
After a discussion with a lawyer that had represented a company after a fairly major accident, I had several ideas about how cheap root cause analysis (RCA) when doing an incident investigation could cost a company millions of dollars. I thought,
“I need to share these ideas to keep management from making these mistakes.”
So this article is about the following three thoughts of how trying to cut costs on your root cause analysis and incident investigations can cost a company big bucks…
1. CHEAP INVESTIGATIONS
I’ve seen many companies assign supervisors to investigate accidents “in their spare time.” This is definitely a cheap investigation. But the problem is that the results could cost the company millions of dollars.
Let’s say that a near-miss doesn’t cost anything and no one is seriously injured. Therefore, a supervisor does a quick investigation without looking into the problem in too much detail. He recommends re-training those involved, and the training is conducted days later. Case closed!
However, the root causes and failed safeguards for a bigger accident are never fixed. Nearly a year later, a major accident occurred that could have been prevented IF the root causes of the previous near-miss had been found and fixed. However, because a “cheap” investigation was performed, the causes were never identified, and 10 people died needlessly. The company spent $1 million on an OSHA fine and almost $100 million more on legal and settlement costs.
What do you think? Was the savings of a cheap investigation worthwhile?
One key to a world-class incident investigation and root cause analysis program is to spend time identifying which “small incidents” are worthy of a good investigation because they have the potential to prevent major accidents. These near-misses of a big accident (precursor incidents) should be treated as seriously as the big accident itself. It deserves a thorough investigation, management review, and implementation of effective corrective actions to prevent the recurrence of the causes (and, thus, the big accident that’s waiting to happen).
2. CHEAP CORRECTIVE ACTIONS
I’ve seen companies try to perform a thorough root cause analysis only to try to take the cheap way out when it comes to corrective actions.
You have probably all seen “cheap” corrective actions. Try these:
- Caution workers to be more careful when …
- Re-train employees to follow the procedure.
- Re-emphasize to employees the importance of following the rules.
These seem cheap. (Cautioning employees is almost free.) But they change very little. These corrective actions will be forgotten in days or months. Plus, new folks who join the organization after the caution, re-train, or re-emphasis occurs won’t get the repeated emphasis.
What happens? The incident tends to repeat after a period of time. And repeat incidents can be worse and more expensive. Thus by saving on corrective actions, you may be costing your company big bucks.
Instead, for investigations that could prevent major accidents, investigators should propose (and management should insist upon) corrective actions that remove the hazard, remove the target, or significantly improve the human factors of the safeguards that are used to prevent a repeat of the accident. These may not be cheap, but they will be infinitely more effective.
What if one of these three choices can’t be implemented? Then one or more additional safeguards that are effective should be developed.
3. CHEAP TRAINING
The legal counsel that I was talking to told me that many “TapRooT® Users” he ran into during their preparation for trials had never been formally trained in TapRooT®. The attorney had attended one of our public TapRooT® Courses. He was amazed that management at fairly major companies would assign people who had never been to ANY formal root cause analysis training to investigate serious incidents that had the potential for expensive legal outcomes.
In one instance, the person using TapRooT® Root Cause Analysis had obtained one of our old TapRooT® Manuals from a friend. He then “used” the technique after reading “some” of the manual. He didn’t have a Root Cause Tree® Dictionary or a Corrective Action Helper®. His reading didn’t provide him with the knowledge he needed to use the most updated TapRooT® System correctly when investigating serious incidents.
Don’t get me wrong; the TapRooT® Manual pictured above was a great read 30 years ago. But I would never recommend reading that old manual as the only source of training for someone who will be investigating serious accidents (fatalities and major environmental releases). What would I recommend? The 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. With the course, they would get the new book, TapRooT® Root Cause Analysis for Major Investigations, and the latest Root Cause Tree® Diagram, Dictionary, and Corrective Action Helper® Guide, plus a 90-day trial of the TapRooT® Software.
The attorney also mentioned that he frequently meets TapRooT® Users who are out of practice using TapRooT® RCA. They really need a refresher because they don’t have many serious accidents to investigate and don’t get any feedback even when they do a simple investigation. I told him that they should ….
- Be using TapRooT® proactively to get practice using the techniques.
- Set up a company peer review process to help users get better at applying the techniques.
- Attend the Advanced TapRooT® Skills Track or the TapRooT® Immersion Experience Track at the Global TapRooT® Summit to keep up with the latest improvements in the TapRooT® Techniques and refresh their skills.
By the way, what had the “fairly major accident” cost the company that the attorney was calling me about? Because they weren’t doing an effective root cause analysis, the incident they experienced cost over $50 million dollars in costs (including settlement costs and legal fees). He thought that…
Highly competent, practiced TapRooT® Investigators
are a very important investment for a company.
He was going to advise his client (the company’s management) that they need to understand what is required to perform a successful incident investigation and then invest in their incident investigators’ training and the time to perform superior root cause analysis. He hoped he could convince them that saving on root cause analysis training is a stupid idea (or maybe he said he would convince them that the investment was a smart idea).
I told him that he should also let them know about one of our newest courses, the:
What Can You Learn From This Conversation?
Thorough root cause analysis of a precursor incident is an important investment.
For a thorough investigation, you must have well-trained investigators who know what they are doing.
Once you have excellent investigators, make sure they have the time and resources needed to investigate all precursor incidents. Saving money on what seem like simple investigations (but are actually precursor investigations) is a fool’s mission.
As Benjamin Franklin said:
An ounce of prevention is worth a pound of cure.
Corrective actions that prevent major accidents are important investments.
When it comes to the corrective actions recommended for precursor incidents, management should insist upon effective corrective actions that go beyond training. Saving money by implementing “cheap” corrective actions is a false saving. It can come back to haunt the company. Plus, management should realize that these corrective actions are an investment in their own career. They don’t want to be responsible for a major accident.
So, please tell your management:
DON’T MAKE THESE MISTAKES!
Invest in effective root cause analysis and prevent major accidents from occurring. And get them to attend the upcoming TapRooT® Executive Leadership’s Role in Root Cause Analysis Course.