Root cause analysis is just one part of conducting a thorough investigation following an EHSQ event, but it is key to knowing what corrective action to take. Hand in hand, root cause analysis and corrective actions mitigate the risk of recurrence; however, time and time again, we hear about a disaster where the issues had been identified but the remedies had not been actioned. This is down to poor management of the corrective action process.
The most in-depth root cause analysis will be of no benefit if its findings are not acted upon to make sure a similar set of events cannot cause an incident again. Corrective and preventive actions (CAPAs) are part of the four important questions to ask during a root cause analysis:
- What happened?
- How did it happen?
- Why did it happen?
- What needs to be corrected?
Given that serious accidents are likely to have the same root causes as minor ones – the severity it often just a matter of chance – failure to implement changes can lead to catastrophic consequences. A successful root cause analysis, along with witness statements, employee conversations, and inspections findings, is required in order to set corrective actions that will be effective.
What a root cause analysis will find
Once it has been determined that an event requires investigation (usually based on a risk matrix), analysts can get to work on discovering the root causes. There are many researched methods to achieve this goal; for example, the 5-Whys model is a simple to follow series of “why” questions that involves conversations with employees, but something more systematic such as a Bowtie Analysis may be more appropriate to investigate higher severity events.
How do you choose the right method? This depends on the tools available to you and your analysts. Conducting a root cause analysis is a skill in itself – especially when using highly mathematical methods such as the Fault Tree Analysis developed for military and defense organizations. If Bowtie, Fault Tree, Tripod and Fishbone sound like a collection of buzzwords to you, read our 5 Methods of Root Cause Analysis guide to understand their differences, strengths and weaknesses.
A root cause analysis will discover a collection of failures or circumstances that led to an event. Borrowing terminology from the Tripod Beta method, these can be immediate causes, preconditions, and latent failures (underlying causes). A factor is considered a root cause if its removal from the sequence prevents the event from recurring.
Each failure should require an action to remedy it. Actions related to immediate causes are usually carried out onsite, whereas latent failures are typically handled by management and can take longer to address due to their legacy. Nevertheless, all corrective and preventive actions need to be assigned, tracked and completed.
Why corrective actions don’t get completed
Despite the best intentions following an event, over several months, complacency creeps back in. Our perception of risk decreases with the passing of time, in what is known to psychologists as the Example Rule. Following a root cause analysis or incident investigation, corrective actions can be overlooked for various reasons:
- People are busy and follow up actions are easily forgotten about in the myriad of other daily tasks
- There is no oversight on outstanding task items whether at corporate or site level
- A lack of communication around why corrective actions matter and how they directly impact worker safety
It is the job of the EHS Director to instill and nurture a culture that avoids these issues, which requires a combination of clear communication, mutual respect amongst workers and management, and technology.
How to implement and verify corrective actions
Corrective actions are sometimes referred to in the context of Corrective and Preventive Actions (CAPAs). An action resulting from a root cause analysis may be corrective (corrects immediate causes) or preventive (addresses preconditions and latent failures to prevent recurrence). Regardless, all actions should be appropriately prioritized, organized, automated, and analyzed.
Prioritization and the Pareto principle
Investigations sometimes generate dozens of corrective actions. However, like most items in EHS management, there should be prioritization involved. Prioritizing certain actions over others helps break down the workload, which can otherwise garner an approach of “I didn’t know where to start, so I didn’t start.” To prioritize, you can calculate:
Priority = easiness x important x urgency
And assign a level to each corrective action. You may also have heard of the Pareto principle, which theorizes that 80% of problems can be attributed to about 20% of the issues found in a root cause analysis. This is good news for EHS Managers. Going by this 80/20 rule, investigators can prioritize CAPAs to solve the major issues first.
Stay organized by utilizing technologies
With multiple tasks to manage, all with their individual owners, locations, timeframes and priority levels, an investigator must be extremely organized. It goes without saying that technology is hugely beneficial for productivity in action management.
For best practice, you’ll want a digital Action Manager that holds all CAPAs relating to root cause analysis findings. This will let you see who has been assigned what, why, and when it’s due – providing oversight and creating accountability. It’s not recommended, but cash-strapped EHS departments can also use well-known programs such as Excel to organize items.
Automate reminders with an Action Manager system
The functions of an Action Manager system do not stop with listing tasks. This kind of technology can also remedy the top reason actions aren’t carried out – they are forgotten about. With automated notifications, action owners receive can receive numerous reminders that their action is approaching due date.
But how can you know when a corrective action is completed? A central Action Manager can require that evidence is attached by the action owner that proves they’ve done their duty. And if the due date comes and goes, escalation workflows can move up the chain of command to notify senior staff members to look into why the action has not been completed.
Analyze and communicate the positive results
By tracking the close out of actions in an Incident Management System alongside data from incidents and observations, you can surface this information in dashboards and reports. This is particularly helpful to identify trends, not only where performance is slipping but in the case of improvements. For example, following a series of corrective actions, the number of hazards being observed onsite may fall over time. These results should be communicated across the business to support the necessity of corrective actions.
In summary, stemming from an appropriate root cause analysis, corrective actions are powerful tools in mitigating risk across a business. It is as simple as identifying what went wrong and doing something about it. But that’s not to say it is easy; you’re going to require tight organization, reliable technology, accountability, and a deep-rooted understanding of the disastrous consequences of failure to act. Otherwise, your incomplete corrective actions may end up as causal factors in the next root cause analysis.
5 Methods of Root Cause Analysis for EHS Incidents
Understand the basics of 5 of the most popular RCA techniques, with a how-to guide, an example, and pros and cons of each. Root Cause Analysis is only one block of an incident investigation building, but if you want to start with a strong foundation in the practice, download this whitepaper for help.