What Do Repeat Incidents Mean?
The UK Rail Accident Investigation Branch Chief Inspector commented in their 2012 Annual Report that many of the rail accidents investigated are repeats of previous accidents. These included workers struck while working near the tracks, crossing accidents, and equipment failures.
These repeat failures aren’t surprising to me. I see repeat failures across many industries. In fact, repeat failures were the reason we started developing TapRooT®! We even included two specific causes for repeat failures in TapRooT®’s root causes – Corrective Actions Need Improvement and Corrective Actions Not Yet Implemented.
But what are the Generic Causes behind these two root causes? There are three common ones that I will mention here.
First, failure to perform adequate root cause analysis. Addressing symptoms rather than root causes leads to repeat incidents. Good root cause analysis should lead to effective corrective actions. Effective corrective actions should dramatic-ally reduce (or eliminate) incidents.
Second, Corrective action backlog. If you don’t implement corrective actions, they can’t work. Some management teams don’t place much emphasis on corrective action implementation. Thus, incidents that should have been prevented instead are repeated!
The third problem is ineffective corrective actions. Even if a problem’s root cause(s) is identified, an investigator or management could assign weak or ineffective corrective actions. That’s why SI developed the Corrective Action Helper® Module – to make corrective actions more effective for every type of root cause on the Root Cause Tree®. Also, in TapRooT® Training we teach using the most effective safeguards and defense in depth when developing corrective actions.
Your root cause analysis and corrective action programs should show their effectiveness by producing a dramatic decline in incidents. If they don’t, the programs need improvement. Where can you learn to improve them? At a TapRooT® 5-Day Course or at the TapRooT® Global Summit. Get more info today!
