Continuous Improvement Through Root Cause Analysis

When an untoward event occurs that results in an injury, fatality, major equipment damage or loss of substantial revenue, most companies launch an investigation. These investigations are necessary to determine what happened, why it happened, and what can the company do to prevent recurrence. The manner in which these investigations occur vary based on the company and the context and severity of the event, but the commonality is that they do occur.

Related but substantially different is how companies respond to events that could have, but didn’t, result in an injury, fatality, major equipment damage or loss of revenue. These events are often referred to as near-misses, or tier 2/3/4 incidents. Often these events are given cursory, if any, attention with respect to root cause analysis. At first blush, this is understandable. We work in competitive and fast-paced environments where the next shiny object is always beckoning for our attention. As a result, we often convince ourselves that we have neither the time nor the resources to fully flesh out the root causes beneath every near miss or Tier 2 event. 

Reasonable people can disagree on the how to allocate resources in response to near misses or minor events; however, I contend that there is an element that should be taken into account when making this decision which is frequently overlooked. Specifically, the quest for continuous improvement.

Assume you are coaching a baseball player that was committed to improving his hitting. You are filming an at-bat which you will review with him later. During this at-bat, he swings and misses on the first two pitches. One the third pitch he laces a rocket into the left field seats for a home run. While reviewing the film with him afterwards, where should your attention be if your objective is to help him improve his hitting? I would contend that you should focus on the first two pitches where he swung and missed. This assumes the objective is to get better. If the objective is feel good about ourselves, then there is no need to review the first two pitches, after all, the plate appearance led to a home run. However, if we choose to devote no resources towards evaluating the first two pitches, we must also accept that we have done nothing to help him improve his batting.

In the ultra-competitive world in which we live continuous improvement is not a luxury. It is a survival criteria. Those organizations that learn quickly and effectively will outperform those who don’t. Many organizations improve solely as a function of experience. Meaning, as their team gains experience resulting from showing up and performing their work, they will, in fact, improve. However, this is true of every organization. Therefore, there is no relative advantage of relying solely on experience for continuous improvement because this only allows you to pace with the pack. To break free from the pack and gain market share and increase margins, we must capture ways to learn more efficiently.

This is the power of the root cause analysis for near misses and minor events. If done properly, they can serve as the catalyst for an organization’s continuous improvement. “Done properly” is the key phrase in that sentence. Here are some examples of pitfalls that prevent them from being “done properly”:

1.      A cursory review of the event. Using our baseball player metaphor – “you swung and missed. Next time try to hit it.”

2.      A too detailed review of the event where every aspect is scrutinized with such detail that the process drains resources from the organization which are not sustainable.

3.      Playing the blame game. This went wrong, or almost went wrong, who’s fault is it and what consequences will they face?

4.      Corrective actions that overly burdensome which increase the likelihood of non-compliance. The best corrective actions are based in common-sense and often make the team’s job more manageable not less.

In the book “Extreme Operational Excellence” (which I co-authored with Bob Koonce), Chapters 7 and 8 are dedicated to root cause analysis and dive deeper into what makes them effective. Suffice to say for the purposes of this post, if we look at each near miss and minor event as an opportunity to improve and base the resources that we are willing to utilize in order to improve, we are likely to find the power that root cause analysis has in improving our safety, operational and financial performance.

Matt DiGeronimo is retired U.S. Submarine Force Officer. After the Navy he succeeded in running a portfolio of district energy power plants for Veolia North America as Vice President of Operations. As a senior consultant for High Reliability Group, Matt frequently speaks and writes on Operational Excellence (co-author of “Extreme Operational Excellence”) and High Reliability Organizations based on the leadership and culture of the U.S. Nuclear Navy. You can learn more about High Reliability Group by visiting www.highrelgroup.com.