Root cause analysis (RCA) is just one part of an EHSQ event investigation, but it is key in knowing what corrective action to take. However, too often there are still major injuries, illnesses or harm where the root causes were previously identified but the remedies not 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 prevent recurrence. 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, failure to implement changes can lead to catastrophic consequences. Therefore, an investigation that includes gathering the facts through root cause analysis and witness statements is required, in order to set the right corrective actions.
What a root cause analysis will find
Once you determine an event requires investigation, usually based on a risk matrix, the investigators' job is to find and address root causes.
There are many 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. However, 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 complexity of the incident, and the tools available to you.
Conducting a root cause analysis is a skill in itself – especially when using highly mathematical methods such as the Fault Tree Analysis, originally developed for military and defense organizations. If Bowtie, Fault Tree, Tripod and Fishbone sound like buzzwords to you, read our 5 Methods of Root Cause Analysis guide to understand their differences, strengths and weaknesses.
Root cause analysis will discover a collection of failures or circumstances that led to an event. Typically, this can include Unsafe Actions, Unsafe Conditions, Job Factors, and Personal Factors, and they may be immediate or latent (underlying).
A factor is considered a root cause if its removal from the sequence prevents the event from recurring.
Each root cause requires 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 root cause corrective actions don’t get completed
Despite the best intentions following an event, over several months, complacency creeps back in.
The Example Rule theorizes that our perception of risk decreases with the passing of time. Following an incident investigation, corrective actions can be overlooked for various reasons:
- People are busy and follow up actions are forgotten about in the myriad of daily tasks
- There is no oversight on actions whether at corporate or site level
- A lack of communication around why corrective actions matter and how they directly impact worker safety
EHS professionals must instil 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 corrective actions that get done
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, to prevent recurrence, or preventive, to prevent occurrence.
Subsequently, most actions arising from a root cause analysis may be corrective, as the event already took place. However, an investigation can also uncover harm potential, which is addressed with preventive actions.
Regardless, all actions should be appropriately prioritized, organized, automated, and analyzed.
Prioritization and the Pareto principle
Investigations sometimes generate dozens of corrective actions. Therefore, like most items in EHS management, you must prioritize.
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 × importance × urgency
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.
Organize corrective actions using technology
With multiple tasks to manage, all with their individual owners, locations, timeframes and priorities, an investigator must be extremely organized. So, technology is hugely beneficial for productivity in action management.
Some organizations use Microsoft Excel to manage action lists, which can do the job in smaller businesses, but is limiting for enterprises. In enterprises, you’ll want a digital Action Manager to hold all CAPAs relating to root cause analysis findings across the organization.
Growing logistics company LBC Tank Terminals was in the same situation and have shared their experience going from spreadsheets to software.
Action management software lets you see who is responsible for what, where, and when – providing oversight and creating accountability to get actions done.
Automate reminders to ensure actions get completed
The function of an Action Manager system does not stop with listing tasks. Furthermore, action management software remedies the top reason corrective actions aren’t carried out: that people forget.
With automation, action owners receive notification they've been assigned an action; reminders when it's approaching due date; and escalation up the chain of command if the action goes overdue.
Next, how do you know when a corrective action is completed? Action management software allows owners to mark the action as complete. Moreover, some systems including Pro-Sapien can require the action owner to attached evidence, such as photos, emails or receipts, to prove the action has been completed satisfactorily.
Analyze and communicate the positive results
By tracking corrective actions with Action Manager software, you'll have a wealth of data at your fingertips. For example, the ability to display Overdue Actions as a Key Performance Indicator (KPI) on dashboards helps to quickly highlight issues and keep the business on track.
Furthermore, by utilizing user-friendly business intelligence apps such as Power BI, EHS professionals can identify trends and compare performance. For example, following a series of corrective actions, the number of hazards being observed onsite may fall over time.
To remedy yet another reason why actions don't get completed, EHS professionals should communicate results like this to employees and executives alike to support the necessity of corrective actions.
In summary, stemming from an appropriate root cause analysis, corrective actions are required to mitigate risk across the business. It is as simple as identifying what went wrong and doing something about it.
However, that’s not to say it's easy. You’re going to require tight organization, reliable technology, accountability, and a deep-rooted understanding of the potentially disastrous consequences of failure to act. Let's make sure your incomplete corrective actions don't 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.