Root Cause Analysis Without Tears
About half of my colleagues whose work involves the investigation of harmful events in the high-hazard endeavors express extreme discomfort with the term “root cause analysis” and terms of the same ilk. The other half may be in denial.
Being in the uncomfortable half group and wishing to evade that discomfort, I sought an accommodational solution that would just let me live with the situation. I left the hunt for a fundamental solution to my betters.
I don’t necessarily want the world fixed, but I do want to live in it without being repeatedly slowed down by the root cause terminology speed bump.
Some agencies, organizations, and other entities use terms such as “root cause analysis” and “root cause” inconsistently.
These include the U.S. Environmental Protection Administration, U.S. Navy, U. S. Nuclear Regulatory Commission, U.S. Department of Energy, the Nuclear Energy Institute, the Electric Power Research Institute, the Occupational Safety and Health Administration, the National Institute of Occupational Safety and Health.
Do these powerful and influential entities give a second thought to what they mean by “root cause”? Do they know the impact of calling something a root cause?
Identifying one or more root causes of a harmful effect has pernicious impacts. One such impact is to curtail broader and deeper inquiry. People seem comfortable knowing the root cause or root causes, however weak the bases.
Once people think they know the root cause or root causes, they just move on. This often leads to subsequent harmful events.
How often are these pernicious impacts also nefarious? How often are they parts of intended or inherent concealments?
Some agencies, organizations, and other entities seldom or never use terms like “root cause analysis” or “root cause.” These include the Federal Aviation Administration, the National Transportation Safety Board, the Chemical Safety Board, the U.S. Food and Drug Administration, and the Securities and Exchange Commission.
The dominant newspapers, magazines, and other media generally follow the usage of the entities being reported on.
Five Minutes of Fun: An entertaining and educational exercise is to do an internet search with the following in the search window: name of term user entity, root cause. For example: “OSHA root cause.”
Observation: The search of “OSHA root cause” yielded an item that told investigators to find “all root causes” of an accident.
Lesson to be learned: Discretion is the better part of valor. If the regulator wants all root causes, an investigation that the regulator needs to sign-off on should have all root causes.
OSHA also says, “Incident investigations that focus on identifying and correcting root causes, not on finding fault or blame, also improve workplace morale and increase productivity, by demonstrating an employer’s commitment to a safe and healthful workplace.”
Please raise your hand if you think the tsunami was a root cause of the Fukushima harm.
A search of “NTSB root cause” indicates that NTSB looks for “probable cause” and accepts the possibility that there may be more than one.
The comparable EPA search indicates that EPA goes along with OSHA. The definition used by both agencies is: A root cause is a fundamental, underlying, system-related reason why an incident occurred that identifies one or more correctable system failures.
Of course, this raises issues such as the meaning of “reason,” “system-related,” and “correctable.”
The Mine Safety and Health Administration does its own root cause analyses, but the “root causes” seem superficial and administrative.
The Chemical Safety Board does its own investigations, but varies on the use of the term “root cause.” There is apparently no policy. For example, the Safety Bulletin on the 2015 ExxonMobil Baton Rouge Release and Fire, a sobering example of workers whose competence, training, supervision, and instructions were jointly insufficient to avert deaths, does not mention the term “root cause.”
CSB should be given credit for a tree-like display of causation near the end of the Safety Bulletin on the 2015 ExxonMobil Baton Rouge Release and Fire. Displaying causation is a step toward transparency.
Hand raising: Please raise your hand if you think the tsunami was a root cause of the Fukushima harm. (No one is looking.)
Side trip: Was the tsunami a root cause of the Fukushima harm? It was not fundamental, in that it resulted from plate tectonic movement. It was not system-related, unless you admit to the earth being a system. It does not identify a system failure that is correctable. (Serious question: What good was this side trip?)
Quotation: “There’s balls and there’s strikes, and they ain’t nothin’ till I call ’em.” —The Third Umpire (How does this help?)
Quotation: “I know it when I see it.” —Supreme Court Associate Justice Potter Stewart
Quotation: “The beginning of wisdom is to call things by their right names.” —Confucius
Interim Compensatory Plan
I would rather die with the root cause terminology problem than die from it. So I try to keep a plan in my back pocket in case the issue arises, which it often does.
Personal practice: I openly admit to doing root cause analysis. I frivolously call myself a “rootician,” “rootician by trade,” or the like. I engage in groups that say they are involved in root cause analysis.
I never say that something is a root cause without tipping people off to the existence of a terminology conundrum.
Personal practice: I recommend that investigation teams use their organization’s official definitions of terms.
Personal practice: I recommend that investigation teams not use their current ongoing investigation to refine definitions unless the definitions are part of the causation of the harm being investigated.
Personal practice: I recommend that investigation teams include a glossary in their investigation reports and say where each glossary entry came from.
Personal Practice: I ask the following about claimed root causes and probable causes:
- What were the harmful conditions, behaviors, actions, and inactions that resulted in each of the root causes and probable causes?
- Which of those harmful conditions, behaviors, actions, and inactions have equal or better claim to be called root causes and/or probable causes?
- Which other harmful conditions, behaviors, actions, and inactions were necessary to the causation of the harms incurred?
- Which of those other harmful conditions, behaviors, actions, and inactions have equal or better claim to be called root causes and/or probable causes?
Personal Practice: I never say that X caused Y. I say that X was part of the causation of Y. (It’s a bit long winded, but it is carefully correct.)
Practice: I develop and refine a consistent approach to reading a root cause analysis report.
For Opening Your Own Eyes
Do an internet search with the following in the search window: the name of your favorite agency, root cause. Were you surprised?
There’s more to being a rootician with integrity, but the above is a good start.
How do you personally handle the root cause terminology quicksand?
How does your plan differ from mine?
About the author: William R. Corcoran, Ph.D., P.E., is an industrial safety expert specializing in high-hazard industries and root cause analysis. He is the publisher of the safety newsletter, The Firebird Forum, where this article first appeared (Vol. 20, No. 10, Oct. 2017).
EXPLORE BY CATEGORY
Stay Connected with CBIA News Digests
The latest news and information delivered directly to your inbox.