Root Cause Analysis
What is root cause analysis? An 800 person forum comprised of RCA experts all over the world tried to answer the question. They could not agree on an answer. A smaller group was formed, composed about 10 major RCA consulting groups. They could not agree either. Several professional societies have tried to agree, with same results--nothing.
Think about it. The cause of something that happened today occurred yesterday. The cause of yesterday problems occurs day before that. There is no limit. The causes can be traced back to the beginning of the time.
Because no one really wants to trace any of our problems all the way beginning of the time, each person, consultant or organisation defines root cause differently. The problem with root cause analysis is that it has become whatever people want it to be. If you only want to see problems in your management system, that is all you see.
As you explore varying methods of root cause analysis, note each of these methods are trying to help you see. List of possible causes are evident in these type of methods; Procedural flaw, inadequate training, insufficient barriers etc.
If root cause analysis at your site is only something performed by an elite group of specialists using sophisticated investigative methods, something is wrong. Your RCA ought to be revealing that it is the small things that matter. Unresolved small problems cause big ones. We need to be learning much more from our unresolved small problems. What about ourselves that allow unresolved small problems to exist?
It is okay to start by investigating large problems so you discover the tie between unresolved small and big problems.
RCA is a promising approach with considerable face validity as a way of producing learning from things that have gone wrong. But it has consistently failed to deliver benefits on the scale or quality needed. Though its purpose is to guard against a similar incident in the future, it may instead function primarily as a procedural ritual, leaving behind a memorial that does little more than allow a claim that something has been done.Incident investigation clearly will continue to play an important role in making the things safer, but it must first get better at doing what it does.