Root Cause Analysis - Turns a Near-miss Into Something Great

6/18/2018

Root-cause Analysis, also known as Why-Tree Analysis, is an event-based problem-solving technique that can be used to prevent problem recurrence. Root-cause analysis is based on a basic idea that effective management requires more than just “putting out fires” for problems that develop but finding a way to prevent them. This technique teaches people that problems are nothing more that a system of cause and effect relationships. Simply put, you identify a problem and then work backwards to figure out the real causes of the problem. Then, if you adequately address the causes, then the problem does not reoccur. The key is that you often have to drill down several times to find the true cause of a problem and that there are usually more than one root cause for a problem or event. By repeatedly asking “Why”, you can peel away the symptoms which can lead to the true root cause of a problem.

When do we use it?

As environmental health and safety consultants, we often utilize root-cause analysis to help clients resolve recurring health and safety or environmental compliance challenges. OSHA and/or CUPA audits findings are examples that trigger the necessity to understand the root cause of an accident or non-compliance issue so that those practices can be changed to solve the inherent underlying problem by instituting new procedures, processes or controls.

How does it work?

Here is a humorous example:

You are on your way home from work and your car stops in the middle of the road.

Why did your car stop? – Because it ran out of gas.
Why did it run out of gas? – Because I didn’t buy any gas on my way to work.
Why didn’t you buy any gas? – Because I didn’t have any money.
Why didn’t you have any money – Because I lost it all last night in a poker game.
Why did you lose your money in last night’s poker game? – Because I’m not good at bluffing when I don’t have a good hand.

Now how can you address the root cause?

Don’t play poker.
If you play, don’t gamble all your money.
If you play, don’t bluff.

In a compliance example, you would identify all the ways you can address the root cause and put those into action. Once you have implemented change it is always important to check again and verify the changes solved the challenge.