I have been very fortunate in my career to have learned to perform 5-why or root cause investigation in various industries and using various techniques. This knowledge from automotive, Japanese automotive, food manufacturing, chemical, and nuclear as a facilitator of RCA has given me a very unique perspective of how an effective investigation is conducted. Across all the various methods and industries, I have found there are five very important aspects of RCA that a facilitator must have to drive a successful root cause and corrective action.
Too many times, the RCA was just another item that had a very short deadline along with dozens of other items that everyone had to get done. What this led to was a fast and easy RCA. The team or sometimes individual would look for the obvious and easiest answer to the problem that was at hand. Many times this led to the answer of human error and to conduct a retraining of the process. This was fast, simple, and cost the company no money. This was the perfect way to close the investigation. The only problem is that the training was never sustainable because the team never had the time to really find the real root cause.
The best practice is for the management team to let the facilitator know that the most important task they now have is to really seek the true root cause. That is not only for the facilitator but for anyone who the facilitator will need to complete the investigation. If there are employees, supervisors, or even managers; they should be made available with ample time to work with the RCA team to answer and participate in the process.
If time is not given to the team to do the task, the process will immediately breakdown. There may be corrective actions that are found and implemented, but they will be as short lived just like the time spent performing the RCA. Not to say that an RCA should take an unlimited amount of time, but it should be given the time priority of the team. It should be the priority to find and prevent the incident from happening again, especially when finding ways to keep people safe.
The team must have the resources available to make the right decisions. Of course, there are some things that the team should not have to need to have access too. There are times, though, that the information is not provided in which they need to perform the work.
Access is a very broad term, but it includes items such as data, recreation photos, ability to go see the area, ability to interview witnesses and read statements, and access to those who can aid in the investigation. I found in the chemical industry in particular that there were some key people who had strong knowledge in certain areas. It was those people that we needed access to so as to really understand the complexity or background of an issue.
The RCA team should be able to make requests and have those granted in a reasonable amount of time. It is important that the team and organization knows that the RCA team is to have access to what they need to find the best root cause.
Data seems like a no brainer when it comes to performing a RCA, but too many times this is the part that is overlooked. I remember a metal assembly laceration that I was facilitating. The ruling thought was that too much weld oil had led to the part being dropped and causing the laceration. What we really found was that the rack that held the part was not built to specifications and had an awkward angle that led to the potential for a weak grip. We only got lucky and stumbled on that information when a maintenance person told us about the reported issues with that assembly.
We almost missed a key point of the RCA by assuming we already knew the answer. We were not seeking data. We felt we knew. That is why the data gathering step of any RCA is so important. Some of the data will be useful, some may not be. The key is that you will not know what is and is not useful until you have it all for evaluation. The team should have the data and be able to use it appropriately.
One of the critical aspects of being an RCA facilitator is having independence to be factual and based in reality. Sometimes, it is hard to admit there is a problem with a system or process. The facilitator has to be able to report that without bias, without showmanship, without personal opinion, but with total certainty that it is the truth. I have seen good RCAs go bad when a management team wants to “review” them before publishing. These little tweaks to the process take away the credibility of the work and sometimes gloss over the real issues of the organization.
This is also a deeper topic about the culture of organization. Are you in an organization that wants to learn or are you in one that wants to blame?
High blame = low independence
High learning = high independence
The RCA facilitator has some influence over this, but this is really a much larger cultural process. It is necessary, though, to allow the process to freely flow. Once people see that the process clouded by political judgement, the faith is the process is lost. This creates a significant degradation in the RCA process and corrective actions that are effective.
RCA is not common sense and it is not something the people learn on the fly. It is absolutely necessary that RCA facilitators are educated on the processes and procedures of the organizations investigation expectations. In my experience, I have always asked to be trained in the company’s RCA process. Some use the fishbone, 8D, charting programs, is is-not, 5-Why, and others. Those who perform the process need to know what process to follow.
The best way to comply with the expectations is to write them in a procedure. This creates the standard for the way the RCA process should work and the standard that the process will be graded to. It sets the groundwork for having a strong team and being able to benchmark when there is turnover. It has always been a relief to be able to come into an organization and find a procedure to explain the investigation process. This helps in giving clarity and streamlines the training. The key is to assure that the program can be sustained. A procedure helps to do that.
RCA facilitation can be a complicated process. There are ways, though, to make it an easier and more efficient methodology. Through making sure that the basics are provided for the team, the process will then drive a good solution. The goal of any RCA facilitation is to learn, correct, prevent, and improve. It is through allowing the facilitator to have time, access, data, independence, and training that this can be accomplished.