RCA Investigations: The Challenge of Getting Past ‘Done’

by Dave Righthouse – Senior Project Manager, Plant Operations

Whew! Your facility has had an incident. You’ve been diligent about conducting a thorough Root Cause Analysis (RCA) investigation: you’ve assembled a competent and engaged RCA team, gathered information and photos, conducted interviews, and built an extensive Cause Map. Everyone has participated in creating and selecting solutions.

Now it’s time to implement those solutions. Yet this last step of the process seems to be more difficult than all the others combined. How do you convince those around you to implement these changes? How do you convince those with the authority to approve them that these solutions are not only feasible but essential? That they’ve been well thought out and meet all the objectives of our RCA process; that they’ll help detect when conditions are ripe for a repeat; that they’ll prevent a recurrence and – if a similar event should ever happen – the proposed solutions will help mitigate the consequences of that event.

Aviation psychologist John Lauber, who has worked for NASA and the
NTSB, came up with the concept of Crew Resource Management.

And still we pause…we linger before implementing the solutions or learning the new work processes.

We’re aware that one of the outcomes of a good RCA investigation is a change in the work process related to the incident. As Einstein remarked, “It’s insane to think we can continue doing the same things over and over again and expect different results.” The participants have accepted that the solutions they agreed on will change those processes – either through changes in behavior or changes in conditions or both.

Here are a couple of tools to help get those solutions across the finish line. The first, Crew Resource Management (CRM), outlines an approach for pushing ideas upward in the chain of command without fear of resistance or retribution:

  • Opening or Attention Getter – ‘We have an issue that needs immediate attention.’
  • State Your Concern – ‘I’ve been noticing that….’
  • State the Problem as You See It – ‘If we continue along these same lines, I think ….’
  • Propose a Solution – ‘However, if we take this corrective action, I believe it will improve….’
  • Obtain Agreement – ‘If you agree, I’ll get it started.’

CRM is a set of training procedures for use in environments where human error can have devastating effects. Used primarily for improving air safety, it focuses on interpersonal communication, leadership, and decision-making in the cockpit of an airliner. The term was coined by NASA psychologist John Lauber, who had studied communication processes in cockpits for several years. The concept was intended to foster a less authoritarian cockpit culture in which co-pilots were encouraged to question captains if they observed them making mistakes.

CRM is used in a variety of settings – emergency rooms and firefighting crews as well as cockpits – wherever there’s a hierarchical relationship in a small group of people. It attempts to optimally utilize all available people, procedures and equipment to improve safety and efficiency of operations.

The second tool, ‘E2S2,’ was affectionately named by NAES Safety Director Dave Jackson at this year’s NAES Safe Conference. Shorthand for ‘Excite, Educate, Support and Sustain,’ it works well for installing a new process:

  1. Excite. Get people excited about learning the new process – about the benefits to their career, to their everyday job, to their personal life and the lives of others. Learning something new is work. If you get them excited, they’ll invest the time and energy required to study and practice.
  2. Educate. Explain how the new process came to be, how it will work, how it will modify conditions and/or behaviors. Educate a few who can evangelize the benefits to their teammates. Make sure the training is relevant to your workplace and incorporate tools that can be used every day in the real world of your work. Don’t train people in an abstract, hypothetical way and expect them to apply it to real life. Once you’ve presented the training, have them roll up their sleeves, try it, talk about it, practice with others, watch others and learn by example.
  3. Support. Managers, senior managers and leaders need Steps 1 and 2 as well. You need to excite them about the benefits and educate them on why the solution is important and how to accomplish it. They won’t need all the training, but some education is essential if they are to help change the culture into one that recognizes the value and supports the use of the new process.
  4. Sustain. Continue to provide the resources needed to meet your objectives – and continually communicate the changes and report on the status. Monitor the results to ensure you’re attaining the outcomes you expect.

The Takeaway 

CRM – Crew Resource Management – enables each team member to contribute more effectively. There’s a willingness to report unsafe acts or poorly executed tasks and, more importantly, an eagerness to learn from them. Such a culture produces a collective mindfulness and allows open discussion of where the edge lies between productive and dangerous activities.

To be effective, leaders and managers need to promote cooperation among their people. One way to do this is to make it safe for them to propose solutions even though conflicting goals may exist. Then, once a solution is developed, employing ‘E2S2’ – Excite, Educate, Support and Sustain –  can ensure a safe and effective outcome.

When our facilities can operate in a culture where improving work processes is welcomed and supported, we can truly consider ourselves a learning organization – one in which continuous improvement becomes the norm, our efforts to improve produce more substantial results, and what we consider ‘our best’ today will be even better tomorrow.