Root Cause Tip: Audit Your Investigation System (A Best of The Root Cause Network™ Newsletter Reprint)
AUDIT YOUR INVESTIGATION SYSTEM
AUDIT TO IMPROVE
We have all heard the saying:
Tom Peters changed that saying to:
“If it ain’t broke, you aren’t looking hard enough.”
We can’t improve if we don’t do something different. In the “Just Do It” society of the 1990’s, if you weren’t improving, you were falling behind. And the pace of improvement has continued to leap forward in the new millennium.
Sometimes we overlook the need to improve in places that we need to improve the most. One example is our improvement systems. When was the last time you made a comprehensive effort to improve your incident investigations and root cause analysis?
Improvement usually starts by having a clear understanding of where you are. That means you must assess (inspect) your current implementation of your incident investigation system. The audit needs to establish where you are and what areas are in need of improvement.
AREAS TO AUDIT
If we agree that auditing is important to establish where we are before we start to improve, the question then is:
What should we audit?
To answer that question, you need to know what makes an incident investigation system work and then decide how you will audit the important factors.
The first research I would suggest is Chapter 6 of the TapRooT® Book (© 2008). This will give you plenty of ideas of what makes an incident investigation system successful.
Next, I would suggest reviewing Appendix A of the TapRooT® Book. Pay special attention to the sample investigation policy and use it as a reference to compare to your company’s policy.
Next, review Appendix C. It provides 16 topics (33 suggestions) to improve your incident investigation and root cause analysis system. The final suggestion is The Good, The Bad, and The Ugly rating sheet to rate your investigation and root cause analysis system. You can download a copy of an Excel spreadsheet of this rating system at:
Next, review the requirements of your regulator in your country. These will often be “minimum” requirements (for example, the requirements of OSHA’s Process Safety Management regulation. But you obviously should be meeting the government required minimums.
Also, you may have access to your regulators audit guidance. For example, OSHA provides the following guidance for Process Safety Management incident investigations:
“12. Investigation of Incidents. Incident investigation is the process of identifying the underlying causes of incidents and implementing steps to prevent similar events from occurring. The intent of an incident investigation is for employers to learn from past experiences and thus avoid repeating past mistakes. The incidents for which OSHA expects employers to become aware and to investigate are the types of events which result in or could reasonably have resulted in a catastrophic release. Some of the events are sometimes referred to as “near misses,” meaning that a serious consequence did not occur, but could have.“
“Employers need to develop in-house capability to investigate incidents that occur in their facilities. A team needs to be assembled by the employer and trained in the techniques of investigation including how to conduct interviews of witnesses, needed documentation and report writing. A multi-disciplinary team is better able to gather the facts of the event and to analyze them and develop plausible scenarios as to what happened, and why. Team members should be selected on the basis of their training, knowledge and ability to contribute to a team effort to fully investigate the incident. Employees in the process area where the incident occurred should be consulted, interviewed or made a member of the team. Their knowledge of the events form a significant set of facts about the incident which occurred. The report, its findings and recommendations are to be shared with those who can benefit from the information. The cooperation of employees is essential to an effective incident investigation. The focus of the investigation should be to obtain facts, and not to place blame. The team and the investigation process should clearly deal with all involved individuals in a fair, open and consistent manner.“
Also, OSHA provides more minimum guidance on page 23 of this document:
Finally, another place to network and learn best practices to benchmark against your investigation practices is the TapRooT® Summit. Participants praise the new ideas they pick up by networking with some of the “best and brightest” TapRooT® Users from around the world.
Those sources should provide a pretty good checklist for developing your audit protocol.
AUDIT TECHNIQUES (PROTOCOL)
How do you audit the factors that are important to making your incident investigation system work? For each factor you need to develop and audit strategy and audit protocol.
For example, you might decide that sharing of lessons learned with employs and contractors is a vital part of the investigation process. The first step in developing an audit strategy/protocol would be to answer these questions:
- Are there any regulatory requirements for sharing information?
- What is required by our company policy?
- What good practices should we be considering?
Next, you would have to develop a protocol to verify what is actually happening right now at your company. For example, you might:
- Do a paper audit of the practices to see if they meet the requirements.
- Go to the field to verify workers knowledge of past best practices that were shared.
Each factor may have different techniques as part of the audit protocol. These techniques include:
- paperwork reviews
- field observations
- field interviews
- worker tests
- management/supervision interviews
- training and training records reviews
- statistical reviews of investigation results
To have a thorough audit, the auditor needs to go beyond paperwork reviews. For example, reading incident investigation reports and trying to judge their quality can only go so far in assessing the real effectiveness of the incident investigation system. This type of assessment is a part of a broader audit, but should not provide the only basis by which the quality of the system is judged.
For example, a statistical review was performed on the root cause data from over 200 incident investigations at a facility. The reviewer found that there were only two Communication Basic Cause Category root causes in all 200 investigations. This seemed too low. In further review it was found that investigators at this facility were not allowed to interview employees. Instead, they provided their questions to the employee’s supervisor who would then provide the answers at a later date. Is it any surprise that the supervisor never reported a miscommunication between the supervisor and the employee? This problem could not be discovered by an investigation paperwork review.
Don’t forget, you can use TapRooT® to help develop your audit protocol and find the root causes of audit findings. For example, you can flow chart your investigation process as a Spring SnapCharT® to start developing your audit protocol (see Chapter 5 of the 2008 TapRooT® Book for more ideas).
WHO SHOULD AUDIT & WHEN?
We recommend yearly audits of your improvement system. You shouldn’t expect dramatic improvements every year. Rather, if you have been working on improvement for quite some time, you should expect gradual changes that are more obvious after two or three years. This more like measuring a glacier moving than measuring a dragsters movement.
Who should perform these audits?
First, the system’s owner should be doing annual self-assessments. Of course, auditing your own work is difficult. But self-assessments are the foundation of most improvement programs.
Next, at least every three years you should get an outside set of eyes to review your program. This could be a corporate auditor, someone from another site, or an independent (hired) auditor.
System Improvements (the TapRooT® Folks) provides this type of hired audit service (contact us by calling 865-539-2139 or by CLICKING HERE). We bring expertise in TapRooT® and an independent set of eyes. We’ve seen incident investigation systems from around the world in all sorts of industries and have access to the TapRooT® Advisory Board (a committee of industry expert users) that can provide us with unparalleled benchmarking of practices.
GET STARTED NOW
Audits should be an important part of you continuous improvement program. If you aren’t already doing annual audits, the best time to start is NOW! Don’t wait for poor results (when compared to your peers) that make your efforts look bad. Those who are the best are already auditing their system and making improvements. You will have to run hard just to keep up!
(This post is based on the October 1994 Root Cause Network™ Newsletter, Copyright © 1994. Reprinted/adapted by permission. Some modifications have been made to update the article.)