Root Cause Analysis Without Tears

Transcription

1 Root Cause Analysis Without Tears (Special Issue of The Firebird Forum) by W. R. Corcoran, Ph.D., P.E. Page 1 of 5

2 Introduction Root Cause Analysis Without Tears by William R. Corcoran, PhD, PE 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. Backstory The terms Root Cause Analysis, Root Cause, and the like are used inconsistently by some agencies, organizations, and other entities. These include the U.S. Environmental Protection Administration (EPA), the U.S. Navy, the U. S. Nuclear Regulatory Commission (NRC), the U.S. Department of Energy (DOE), the Nuclear Energy Institute (NEI), the Electric Power Research Institute (EPRI), the Occupational Safety and Health Administration (OSHA), the National Institute of Occupational Safety and Health (NIOSH), and the like. 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 pernicious impact is to promote the stopping of both broader and deeper inquiry. People seem comfortable knowing the root cause or the root causes, however weak the bases. Once people think that they know the root cause or the root causes they just move on. This often leads to later harmful events. How often are these pernicious impacts also nefarious? How often are they parts of intended or inherent concealments? Other agencies, organizations, and entities seldom or never use the terms Root Cause Analysis, Root Cause, and the like. These include the Federal Aviation Administration (FAA), the National Transportation Safety Board (NTSB), the Chemical Safety Board (CSB), the U.S. Food and Drug Administration (FDA,) and the Securities and Exchange Commission (SEC). Page 2 of 5

3 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 amusement 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 on OSHA root cause yielded an item that told investigators to find all root causes of an accident. Lesson to be Learned (LTBL): 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. Lesson to be Learned (LTBL): If the regulator wants root causes to be identified and corrected things might go better if your investigation report transparently identifies root causes and indicates that they have been or will be corrected. A search on 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 that is 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 the issues such as what is a reason, what is system-related, and what is correctable. The Mine Safety and Health Administration (MSHA) does its own root cause analyses, but the root causes seem superficial and administrative. The Chemical Safety Board (CSB) 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 1, a sobering example of workers 1 Page 3 of 5

4 whose competence 2, training, supervision, and instructions were jointly insufficient to avert deaths does not mention the term root cause. Causation: 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 3. Displaying causation is a step toward transparency. Hand Raising: Please raise your hand if you think that 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 to 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, A Rootician by Trade, or the like. I engage in groups that say they are involved in Root Cause Analysis. Personal Practice: I never say that something is a root cause without putting root cause in quotations or otherwise 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 Page 4 of 5

5 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: ONE: What were the harmful conditions, behaviors, actions, and inactions that resulted in each of the "root causes and probable causes?" TWO: Which of those harmful conditions, behaviors, actions, and inactions have equal or better claim to be called "root causes and/or probable causes?" THREE: Which other harmful conditions, behaviors, actions, and inactions were necessary to the causation of the harms incurred? FOUR: 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 4. 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? Wrap-up 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? SUBSCRIPTIONS AND BACK ISSUES Subscribe by sending an to TheFirebirdForum-subscribe@yahoogroups.com Several years of back issues are at Page 5 of 5