Root Cause Analysis - methods and best practice

Editor's Notes

1. Welcome to this installment of the Medgate Webinar series and thank you for joining us. Today’s webinar will be Justifying the existence of your Incident Investigation processes.
2. This webinar will consist of 3 parts. Part 1 will define root cause analysis and underline the importance of investigating and identifying root causes of workplace accidents Part 2 will discuss methods and best practices around root cause analysis And, part 3 will look at key steps in reducing risks from happening in the first place I’m Mike Jackson and I’m your moderator today.
3. Thanks Mike--Good morning first of all I would like to introduce myself My name is Shannon Crinklaw. I am a CRSP & CHRP. I am a Medgate CSC who implements Safety & Industrial Hygiene implementations. I have implemented projects for all sizes of organizations including: Boehringer Ingelheim, Southern Star and L.L Bean. I have over 10 years experience in manufacturing including developing and implementing Health & Safety Systems and Programs. I am also trained and/or trainer for some ISO programs, Toyota Safety Way and Problem Solving. I have been involved in developing specific risk assessment programs for over 6000 employee base. Before I jump into my presentation, I’m going to push out a poll and ask you to think about what prompts you to reassess risk within your organization. This is really what we’ll be talking about in the presentation, so it’s a great place to start. We’ll show the results of the poll at the end of the presentation.
4. So, let’s get started. Today my presentation is going to take you through the reasons and method of root cause analysis. We are going to start with looking at why should you do root cause analysis.
5. Root cause analysis is usually completed as part of an incident investigation. So let’s look the trends that are affecting our industries. First off, here is the list of OSHA’s top serious violations. Review Slide As you can see, all violations can result in serious injury.
6. This slide shows you the injuries that are occurring from the violations and further shows the fatal categories of injuries. Review Slide As you can see from this slide, there statistics show the alarming rates of injuries that occurring and the ability to reduce or eliminate these injuries is an opportunity we have as safety professionals.
7. Root Cause Analysis is really based on several Safety theories including this theory by Herbert Heinrich. Basically, this pyramid illustrates the thinking behind preventing injuries. Review Slide.
8. Ultimately, if we fix the unsafe acts and conditions by finding the true root cause and addressing, we should not move to the next level of the pyramid. By eliminating the hazards at the lower levels, we should not see the more severe injuries and as per our statistics slide we showed early, we can save over 400 lives per year.
9. So how do start eliminating and reducing these serious events. First, we have to start looking at who, when, where and what and not focus on the why. Normally, the trigger for this activity would occur when an incident happens or a near miss is reported. We first need to Clarify the Problem and Understand the Problem. This part is just as important so the root cause analysis can actually be well done. The investigation piece isolates what is factual and removes prejudice or premature guesses for root cause. At this point, we are gathering facts and do not ask the question “Why” until we have better clarification of the problem.
10. What are we investigating? Well in order to eliminate and reduce the serious events, we really need to be investigating all types of incidents and occurrences. Now I know that resources are limited for all organizations and this type of activity takes a lot of manpower and time which results in invested cost. However, as the pyramid theory points out, if we started investigating the safety reports, they would never become near misses, which would never become accidents, which would never become serious incidents. As a starting point, good root cause analysis should begin by looking at all incidents and near misses.
11. As your program becomes more sophisticated and evolves, look at safety reports and observations. Ultimately, you can then branch out to looking at root cause within your other programs. Review slide.
12. Now that we know what we are looking at, and we have completed our factual investigation. Now we are going to look at all the facts and clarified problem and start deducing why this event happened.
13. Review Slide. Basically we are trying to find the reason the event happened with the goal of ultimately fixing the cause to avoid future incidents.
14. The root cause method isn’t just used in Safety. Its benefits extend to other areas as well. Review slide.
15. http://www.kellogg.northwestern.edu/course/opns430/modules/lean_operations/ohno-tps.pdf Review Slide This is when we start asking why.
16. Toyota Motors is famous for using root cause analysis in all aspects of their work. Review Slide. And finding the cause allows for fixing things and continuous improvement.
17. Once we start asking the question why we are looking for the cause. There are various layers of causes and you must keep drilling down and asking the question why to get through the immediate causes, and contributing causes until you reach the underlying or root causes. Immediate causes: substandard acts or conditions that lead directly to the accident: Underlying or root causes: inadequacies in the occupational safety and health management system that allow the immediate causes to arise unchecked, leading to the accidents.
18. Without finding the root cause, you are only examining and trying to fix the symptoms. If you correct a symptom or contributing cause, the problem will still re-occur.
19. There are several root cause methods, however, the majority of the methods ensure examination of the following 5 elements. Read Slide. One should consider these factors in combination with the investigation facts to start the root cause analysis. A common pitfall when examining these factors is blaming the man portion. This often ends with results including re-training or behavior issue fixes. The man is the easiest factor to blame and provide countermeasures. Don’t get trapped in jumping to this conclusion and make sure all factors are examined.
20. Let’s look at a few models and how the 5 elements can be used with the models. The issue with this method is often teams start countermeasuring all the brainstormed ideas. A root cause is never determined. This can be a waste of resources because countermeasuring the root cause would be more efficient and effective use of resources and less cost than countermeasuring the various symptoms and not truly understanding why it happened. The affinity diagram organizes a large number of data or ideas into their natural relationships, categories. This method taps a team’s intuition, it is sometimes used in brainstorming. More details: http://asq.org/learn-about-quality/idea-creation-tools/overview/affinity.html
21. Another method used is cause & effect. The Cause-and-effect diagram is a visualization tool for categorizing the potential causes of a problem in order to identify its root causes. The fishbone diagram is also useful in brainstorming sessions to focus conversation. Again – when using this method, the team should continue to drill down and not get caught in trap of countermeasuring several symptoms.
22. My preferred method is the 5 why analysis. 5-Why is a simple approach for exploring root causes and instilling a “Fix the root cause, not the symptom,” culture at all levels of a company. Invented by Japanese Industrialist Sakichi Toyoda, the idea is to keep asking “Why?” until the root cause is arrived at. The number five is a general guideline for the number of Why’s required to reach the root cause level. The root cause has been identified when asking “why” doesn’t provide any more useful information. This method produces a linear set of causal relationships and uses the experience of the problem owner to determine the root cause and corresponding solutions. Most simply, ‘5 Why’ analysis is a process used to find the root cause of a particular incident. By going through each step of the analysis you can identify the symptoms of each incident and use that knowledge to improve your systems over time. 5 is a general guideline A pitfall of this model includes continuing to ask why even after a systematic root cause is found in order to meet the “5” requirement or alternatively stopping at 5 even though the root cause was not found.
23. Other common pitfalls or mistakes include: READ SLIDE To avoid this: Confirm the Facts Continue to question “why” Trying to find cause and effect relationship
24. So let’s look at the 5 why model and some mistakes in action. Bad example: Did not continue to ask why Will not prevent re-occurrences. If fix screen, it will be temporary countermeasure but not systematic. Breaks out into several 5 why – not see facts, need to go out and see and confirm If fix safety screen on this machine, will this still occur again? Only showing symptom of the true problem Often see – “inadequate training” or “inadequate management system” or other non-fixable
25. Now let’s look at a good 5 why tool using the same starting point. Should be able to reverse the 5 why tree using the word “therefore” (1) Examine the Point of Occurrence and think of possible causes without prejudice (2) Gather facts through going out and checking /seeing and keep asking “Why?” (3) Specify the root cause
26. The ultimate goal of root cause analysis is to stop the incident or event from happening again which ultimately leads to injured employees and higher costs for the organization.
27. Finding the root cause allows us to better focus our resources to get results. Once identify root cause, apply countermeasures to the root cause. You will want to Develop as many potential countermeasures as possible, BUT only select the highest value-added countermeasures that will actually correct the problem. This allows for resources to be used most effiently. Create clear and concrete action-plan and you will get the biggest bang for your buck so to speak. If incident happens again, go back and look at previous root cause. Was it correct? Look at the countermeasures implemented to correct root cause, did the countermeasure fail?
28. Continuing to implement root cause analysis and following up with countermeasures will provide continuous improvement for your organization in 2 ways; 1. it will correct the deficiencies which should reduce the injuries and incidents and 2. the process and employees completing the root cause analysis will get better and better at it therefore making the process intuitive and more efficient. Employees will learn from their mistakes and go back and rework the root cause when needed.
29. Completing and properly tracking root cause analysis also allows for trending and tracking. You should see categories of root cause that are used often and where the majority of your issues are falling.
30. Safety software can help gather and organize this information for you including: READ SLIDE
31. A software system gives us the ability to review quantities of information to ensure quality.
32. Another key benefit is that findings can be and should be shared with other areas that may be affected.
33. Here is an example of a report that will show you the root cause analysis being completed. This report may prompt me to dig deeper and review the incidents/events that inadequate work standards are tied to. Is this becoming an issue company wide? , what can we do globally within the company to fix problems before they arise? Maybe I should consider upgrading the audit program to check work standards more frequently?
34. When I look a little deeper, I can use a decision tree model for easy visualization of ‘5 Why’ root cause analysis. With this non-linear method of root cause analysis, you can: Track multiple reasons and sub-reasons as to why the event may have occurred Select the most fitting underlying cause to include on the incident record This will show me the employee’s thinking way for me to better understand how the conclusion was made. Once you are satisfied with the data you’ve collected, you can begin the approval process; your decision tree will be stored on the record for future review if needed.
35. In conclusion, root cause analysis is a crucial part of any safety management system. It can be used as both a prevention tool and learning tool for your organization. Safety teams that make Root Cause Analysis central to their day-to-day activities will significantly better their ability to improve the safety of the workplace and ensure that incidents do no reoccur. And corrective action systems implemented based on finding the root cause are more efficient, less costly and more effective systems. I hope you found value in the tips talked about today. Thank you for your time.