When do you need a root cause analysis?
I heard one industry guru say that EVERY loss deserves an investigation and corrective action.
Is it possible?
Is it desirable?
I would say no.
Not every loss needs an investigation and certainly not every loss deserves a root cause analysis.
Because every investigation should have at least a chance of a positive return on the investigation investment. Many losses are too small to get much benefit from an investigation. (This is true even if you take into account the potential for even bigger problems down the road.) Let’s face it, sometimes there just isn’t much to learn from a paper cut!
Why should we avoid wasting our improvement energy on unimportant minor problems?
Because every organization has resource limitations and we should spend our resources wisely. We need to put our effort where it will do the most good.
Therefore, we must target our resources where they will get the most improvement bang for the buck.
The targeting of improvement resources should match management’s goals. This targeting of resources should guide the improvement effort by assigning resources for safety, quality, reliability, productivity, and product improvement. Of course, the division of resources is guided by the company’s risk assessment and market analysis.
Let’s look at an interesting hypothetical example.
At a large chemical company, a budget and level of emphasis has been assigned for safety improvement. How should the company spend this budget? Where should the safety team direct their resources?
The first place to look would be the company’s real accident data. Of course, if the company has poor root cause analysis, the data will not be meaningful. If that is true, the first place to apply resources is to achieving outstanding root cause analysis of significant accidents.
What if this company has been applying advanced root cause analysis for several years and has fairly good accident data. Then they can use that data to determine where their biggest risks are and what type of root causes contribute the most to that risk. That knowledge can help them target their resources.
If a company’s safety improvement programs are fairly ineffective (measured by the fatality count), the majority of the emphasis should be put on the investigation of significant incidents and precursors to significant incidents. These are incidents that cause fatalities and serious injuries and incidents that could have caused a fatality or serious injury if one more Safeguard had failed.
The remaining improvement effort (say 33%) would be applied to proactive improvement. This includes local safety audits, peer observations, management field observations, and outside audits.
As the company improves, their safety performance and the time between significant incidents will improve significantly (do you trend this?). As this happens, effort is shifted from reactive investigations (because there are less of them) to targeted proactive improvement. This tends to cause an excelleration in the improvement progress.
What happens if you don’t have good root cause analysis of significant incidents?
If a company does NOT do a good job investigating and fixing their serious incidents, the proactive improvement efforts tend to be miss-directed. The lessons learned from significant injuries and potential significant injuries are inaccurate. The data produced misdirects the proactive improvement efforts. The significant injuries continue even though the minor incidents targeted by the misdirected proactive improvement efforts tend to improve.
This misdirection of proactive improvement efforts has been written about extensively. Proactive behavior based safety improvement efforts produced good trends in lost time injury data with little improvement in fatality and significant injury data. This should not be a surprise. It is the reason that many companies hit a plateau of improvement for major accidents while having world-class lost time injury rates.
I believe an excellent example of this misdirection of improvement efforts could be seen in the BP Texas City Refinery explosion. Management thought their improvement efforts were working because of a decrease in the LTI rate but the fatality rate (that included contractors) was unchanged (or maybe slightly worse).
Where are you????
Are you trending the time between serious injuries and fatalities?
Is that time increasing significantly?
Do you know how to tell if the time between incidents is increasing significantly?
We can help you learn how to mathematically prove that improvement is occurring (or that things have taken a turn for the worse).
Are your less significant incidents improving without making much impact on your significant injury rate? This is a sign of a misdirected improvement effort and a need to improve your root cause analysis of significant injuries.
We can review your program, point out potential improvements, and teach your folks how to apply the best root cause analysis techniques reactively and proactively to make improvement happen.
We can also help your management understand their impact on improvement. How they directly influence the quality of the root cause analysis. (You can’t have excellent root cause analysis without management understanding and involvement.) Even the best root cause analysis systems can’t succeed unless management asks for the appropriate investigations and provides the resources needed to implement effective performance improvement fixes.
Once all of this is on track, we can help you see how to effectively apply your resources to get the most bang for your improvement buck. This includes targeting of improvement efforts and deciding when a root cause analysis is needed and when the effort should be applied elsewhere.
Call Per Ohstrom or Mark Paradies at 865-539-2139 (or CLICK HERE to contact us) to discuss your improvement efforts and see how we could help focus your program to get the best return on your improvement investment.