March 11, 2009 | Dave Janney

Root Cause Analysis Tips; Multiple Root Causes and Writing Corrective Actions

After teaching TapRooT® for the last few months, I’ve been amazed how well students find the root causes to their incidents on their first few trips through the Root Cause Tree®, but then again, that is the point!  However, I’ve noticed one tendency that I want to discuss and hopefully make your job easier.

First of all, when you get several root causes for a causal factor and they are related, that is just fine; don’t get confused into thinking one must be chosen over the other.  I’ve also noticed that at times people struggle to come to terms with writing corrective actions when they have root causes that are related.  Let me illustrate with an example:

You’ve had an accident because an employee made a mistake (causal factor) while doing a job.  They received instructions during turnover on what to do, they forgot some of the instructions, and they messed up.  In the old days, we would just fire them, but since we now use TapRooT®, we understand they are just trying to work within the system we (management) have created.  So we get to work:   

Under the Procedures basic cause category, we chose no procedure

Under the Communications basic cause category, we chose no standard turnover process and repeat-back not used.

Under the Management System basic cause category, we chose no SPAC because they did not have a work turnover process.

Under Work Direction, we chose pre-job briefing NI.        

We have identified 5 root causes, so let me ask you a question – how many corrective actions do you need for this example?  Many people say 5, but these are my thoughts:

First, do we really need a procedure for this task?  The guy made the mistake because he did not remember what to do, so maybe a procedure would help.  But was this not really a turnover issue?  If we develop a turnover policy, would we still need a procedure?  That would be a business decision, but I am going to this with one corrective action, which would involve developing a turnover policy, and in this policy, I am going to address repeat-backs and incorporate pre-job briefings into the turnover.  The policy is going to be very specific (a SMARTER corrective action).  

Let’s try one more:

An incident occurred when someone did not use a required procedure and made a mistake (causal factor).  This task is not monitored by management in any way. 

Under the Procedures basic cause category, you chose Procedures not used/not followed and under the Management System basic cause category you chose enforcement NI and audits & evaluations lack depth.  

You have 3 root causes.  You could discipline the guy, you could monitor performance, or you could do both.  But if you do decide to discipline, what about everyone else?  One corrective action to add the checklist usage to your existing audits should solve all of this if done in a SMART(er) way.

My disclaimer; I am not saying all root causes for a causal factor can always be handled through one corrective action, I am saying that many times multiple root causes can be handled with one corrective action.  You might have 10 root causes and 4 corrective actions, for example.  You might have 2 root causes and 2 corrective actions, it just depends on the incident and the facts you have gathering during the investigation.   

Don’t fall for corrective action overload!  One good corrective action can be better than a host of bad ones.  Quality is more important than quantity. 

Work SMARTER not harder!  And Happy Investigating!
P.S. If you have been using TapRooT® for awhile and want to raise the bar, why not consider a 5 day Advanced Root Cause Analysis Team Leader course?  You will learn all of the optional tools, participate in in-depth interviewing and work direction exercises, and learn more about each of the basic cause categories.  Here is the schedule:


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