Cause Analysis is an extremely important Tool to include in your Human Performance “Toolbox.” Unfortunately, Cause Analysis can be a vague term. Cause Analysis can have different meanings depending on the severity of an incident and on the complexity of an incident.
To begin, let’s start with some definitions:
Cause Analysis can be broken up into two forms – Root Cause Analysis (RCA) and Apparent Cause Analysis (ACA). Root Causes are ideally the lowest level at which an incident starts. For simple incidents, these are extremely easy to find and correct. If I trip over a step while reading a text on my iPhone, the root cause is my inattention to a task. For complicated incidents, an investigator might have to dive several layers to find a root cause.
Apparent Causes, on the other hand, are those events or conditions that appear to be the cause of an incident, but they are often symptoms themselves of a deeper issue. Apparent Causes are generally the result of using a tool such as the “5 Why’s.” These investigations, while not as deep as a true root cause analysis, can be beneficial when a root cause isn’t necessary. If the consequences of an event aren’t serious and time is critical, looking for Apparent Causes might be satisfactory. It is situational dependent and up to the investigative team.
Now that we know what root causes and apparent causes are and the difference between the two, we need to clarify one thing. Many times when conducting an RCA, we fail to take the investigation far enough – especially when investigating cases of Human Error.
Though many people won’t admit it, we tend to stop when we find the person that made a mistake. We slap a Human Error label on the Root Cause line and nobody questions it because it makes sense. We found “the problem,’ and the corrective action is easy. Joe made a mistake – Send him home for a few days send him to training. There is no culpability up the chain of command or on the Organization. What we fail to realize is that mistakes made by employees can be symptoms themselves.
What if the employee didn’t have a procedure, or worse, a procedure with mistakes, for a complex task?
What if the employee did have a procedure, but it was common practice to cut a step (something we call Drift, and we’ll cover in a subsequent post)? How do you hold one employee responsible for something everyone does?
What if the employee was specifically told by his supervisor to complete a task a certain way that introduced risk into the procedure?
Finally, the term Root Cause is bad in my opinion because it implies that there is only one root cause. While this may be true in simple situations, it is never the case during complicated situations. Read any investigative report for a major incident, and you’ll generally see many root causes – each a breakdown of a separate system that was intended to prevent such an accident.
This is not intended to be a cause analysis training, but this is an offering of Understanding Human Performance. This post is geared more to bring some attention and focus on what cause analysis really is traps investigators can fall into.
To request more information on Cause Analysis or to see how we can help, please contact us.