What’s the most important information in a root cause analysis?
Welcome to this week’s root cause tips column. So what is the most important information or criteria in a good root cause analysis? (By the way, this is a trick question)
I started a list:
• A timeline of what happened
• Complete evidence
• Identification of causal factors
• Safeguards analysis (what failed)
• Safeguards Analysis (what worked)
• Root Causes substantiated by evidence
• Generic (system) Causes identified
• Corrective Actions that eliminate the root causes
• Corrective Actions that are implemented
• Corrective Actions that have been verified effective
So what do you think? Have I missed anything? Please comment below if you have any other ideas.
And which are the most important?
Yes, it is a trick question. They are ALL important.
For example, what if you did a really good job of collecting evidence and got good root causes but wrote weak corrective actions? Have you ever seen training as a corrective action for root causes that had nothing to do with training? Of course you have, that’s my point.
What if you had great corrective actions but they were never implemented (or checked to see if they were effective)?
The fact of the matter is you have to have all these things for an effective investigation and root cause analysis. It is easy to miss things, we’re all human and we all have different experiences, knowledge, and biases. But the good news is that this is all built into how TapRooT® functions. Just follow the process and you will have a good root cause analysis.
You must know WHAT happened before you can determine why. This is why evidence collection is so important.
You must know WHY before you can write corrective actions. If you do not have good evidence you will miss causal factors and root causes. ALL root causes have to be substantiated with evidence.
You must FIX the root causes. Your corrective action has to specifically address the root causes, has to be implemented, and has to be verified.
Think of it as a chain link fence. If any part of the chain is broken, the fence is compromised, and in this case, so is your investigation.
If you are interested in learning the TapRooT® Root Cause Analysis, our 2-day course offers all the process essentials needed to conduct an investigation including:
- SnapCharT® – a simple, visual technique for collecting and organizing information to understand what happened.
- Root Cause Tree® – a systematic, repeatable way to find the root causes of human performance and equipment problems — the Root Cause Tree® helps investigators see beyond their current knowledge.
- Corrective Action Helper® – help lead investigators “outside the box” to develop effective corrective actions.
Check out our schedule for a course near you: http://www.taproot.com/courses#2-day-incident
I hope I’ve given you some food for thought. Thanks for visiting our blog and happy investigating.