July 14, 2021 | Mark Paradies

The Curse of Apparent Cause Analysis (Updated)

Nuclear Incident Iceberg

Why I Wrote This Article

Back in March of 2006, I wrote about a problem and the article created quite a stir among TapRooT® Users. The problem? People in the nuclear industry were taking a shortcut and thought that the results were “good enough.” I thought it was causing problems for the industry and the problem needed fixing.

Here Is The Original Article

The original article in Root Cause Network™ Newsletter received attention from many. Some have called me to praise the idea of more attention to serious incidents and proactive improvement. Others have questioned my views about NOT analyzing near-misses with “apparent cause analysis.” Some were really mad. They hated the idea that what they had done for years was a curse to the industry.

What Do I Have To Add To This Article Over 15 Years Later?

Some are still practicing Apparent Cause Analysis in its original, substandard form.

Many took my advice after a nuclear industry group came out with recommendations to stop analyzing incidents that weren’t worth investigation and stop fixing things that didn’t need fixing. 

Some even adopted our essential root cause analysis tools and process to reduce their efforts while still getting good results.

Simple Process

But I still hear about facilities in other industries outside the nuclear industry being misled into the fiction that they can just do 20% of the effort and get 80% of the results by applying a technique called Apparent Cause Analysis to improve their safety, quality, or productivity. 

I know they will eventually learn their lesson after wasting time and effort and not getting the improvements they were promised. But I worry about the lives lost, the injuries that were not prevented, the quality incidents that happened, and the productivity that was lost while they failed to get the improvements they needed while thinking that Apparent Cause Analysis was working.

So my advice hasn’t changed all that much in 15 years…

1. Expand good root cause analysis to all precursor incidents. (See the article, “What is a Precursor Incident?“, for the definition of a Precursor Incident. See the article, “Deciding When to Investigate a Precursor Incident (What’s in the Diamond?),” to start defining when you should do an investigation.)

2. Learn to use the Essential TapRooT® Techniques and process (shown above) to investigate low-to-medium risk incidents. (Click HERE for more about the course to teach you these techniques).

3. For those incidents that don’t rate a full investigation, categorize and trend them using advanced trending techniques. Learn more about advanced trending techniques HERE.

4. Save the effort you might have spent doing 1000 short-cut analyses and fixing the assumed problems. Instead, put that effort into a targeted PROACTIVE improvement program based on good root cause analysis and proactive tools to help you stop human error.

Learn more by attending the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course or and the Stopping Human Error Course

Alex teaching the Stopping Human Error Course

Alex teaching the Stopping Human Error Course

Please stop fooling yourself about getting something for nothing!

Categories
Root Cause Analysis, Root Cause Analysis Tips
Show Comments

Leave a Reply

Your email address will not be published. Required fields are marked *