by Dave Righthouse – Senior Project Manager, Engineering Services
The primary objective of any Root Cause Analysis (RCA) program is to prevent recurrences of an incident. The RCA process identifies the underlying causes and generates solutions intended to achieve that end. The people involved in this process learn from it, hopefully in profound ways. Things that were previously unclear to them or totally bewildering now become transparent. Each incident provides numerous opportunities to learn and improve.
But there’s more to it than fostering learning and improvement. A successful RCA brings about some sort of change in the work processes associated with the incident. As Einstein observed, “We cannot solve our problems with the same thinking we used when we created them.” He further noted that “The definition of insanity is doing the same thing over and over again and expecting a different result.” Unless we change our thinking, our work processes or both, we’re likely to suffer recurrences.
That said, we should often view the solutions we implement as ‘Best Practices.’ After all, we’re doing something different that has not been tried before in order to avoid repeating an incident.
A Best Practice or Lesson Learned doesn’t have to qualify as a profound revelation. Even a simple improvement that you’re making – or just something that became clearer to you and your team – will likely be of use to somebody else as well. That’s why it’s important to share even your small advances – so others can maybe avoid an incident that you’ve had to endure. Over the long term, and across our entire fleet, sharing Lessons Learned and Best Practices actually reduces the cost of these incidents, because it makes us collectively safer, more reliable and more cost-effective. So don’t wait for a grand ‘Eureka!’ moment to share your findings.
Beyond merely identifying and sharing them, we’re looking at the overall impact of the solutions we implement. While we generally focus on ways to prevent a recurrence, we also look for solutions that reveal when conditions are ripe for a similar incident to occur. This could be installing an alarm or adopting some other measure that alerts us to a dormant condition that – given the right conditions – could trigger an event or contribute to a ‘perfect storm.’
Lastly, no matter what changes we implement, we’ll never reduce our risk to zero. As long as we continue to operate machinery or perform work of any kind, we’ll be prone to error. But we can at least reduce the odds. Consider the example of a pilot and co-pilot each running through their pre-flight checklist to minimize their chances of missing the same step. If each of them has an individual error rate of 1 in 1,000, the odds of both of them missing any given step are reduced to 1 in 1,000,000.
While this is a great improvement, it still doesn’t zero out the possibility of an incident. So our final objective is to identify and implement at least one solution that – rather than seeking to prevent the incident – attempts to mitigate its consequences. Often when an incident occurs, we find that we’re not as prepared to respond as we ought to be. For example, we might not have sufficient inventory; or we might dismiss an injury as too minor to warrant treatment; or we might not have an effective response plan in place for a particular type of incident.
To sum up, we’ve expanded the objectives of each RCA investigation to include the following:
- Identify and implement at least one solution that prevents this incident from recurring.
- Identify at least one Lesson Learned and disseminate it across the NAES Fleet.
- Identify and implement at least one Best Practice and disseminate it across the NAES Fleet.
- Identify and implement at least one solution that detects conditions that could trigger a similar event. (These raise awareness so that corrective action can be applied before such an event occurs.)
- Identify and implement at least one solution that mitigates the consequences of a similar type of occurrence.
In our NAES RCA Workshops, we discuss these practices, processes and modes of thinking. If you’re interested in hearing more about this training, please drop me an email.Download File