When an Environment, Health, and Safety (EHS) incident occurs, one question inevitably follows: Why did this happen? The answer is rarely simple. Even the most apparently obvious cause may only be the one piece of many previously unnoticed or unaddressed health and safety failures.
What must be uncovered are the root causes of EHS issues. The Occupational Safety and Health Administration (OSHA) and Environmental Protection Agency (EPA) define a root cause as “a fundamental, underlying, system-related reason why an incident occurred that identifies one or more correctable system failures.” Root cause analysis (often abbreviated RCA) presents problem-solving methods that can help EHS professionals uncover these underlying issues. Here we’ll cover the why, what, when, and how of RCA so you can effectively implement it within your organization.
A single root cause often doesn’t result in a single incident. It could be a contributing factor to dozens of seemingly unrelated incidents—including those that have yet to occur, and those that you may not have even considered. For example, if an investigation into a slipping incident reveals poor employee safety training to be the root cause, that issue does not only increase the risk of slips, trips, and falls. It could potentially increase the risks posed by every single hazard in the workplace that the ineffective training was meant to address.
That means a lot is at stake, but it also presents unique opportunities to drive massive improvements. RCA should not merely be viewed as a reactive response to individual incidents. When EHS leaders view entire organizational systems through the lens provided by an effective RCA program, they can apply all lessons learned broadly across EHS initiatives. With this proactive approach, it becomes possible to improve safety performance and regulatory compliance—preventing further incidents before they have the chance to happen.
The key to root cause analysis is a systematic approach. Regardless of your specific methodology, five key steps/principles are generally applied in an effective RCA:
1. Clearly identify and describe the problem. In the case of EHS, this should include the who, what, where, when, and initial whys of an incident or near miss.
2. Establish a timeline/chain of events leading up to the problem. No detail is too small or irrelevant. What led up to the incident, not just the specific events of that day but also larger organizational shifts or changes that preceded it, even if it was months prior?
3. Differentiate root causes from other contributing factors. This can be a bit tricky depending on the incident at hand. This is where you use a 5 Whys approach or Ishikawa diagram to lay out all of your potential causes and create a hierarchy that eventually points to the root cause(s).
4. Depict the relationship between the root cause(s) and the problem in a causal graph. Based on the timeline and causal factors, a causal graph succinctly lays out the evidence demonstrating how a root cause led to the incident and may reveal potential solutions.
5. Recommend and implement decisive action. The critical 5th step in RCA is the implementation of corrective and preventive actions (CAPA). Corrective Action(s) (there is rarely only one) are countermeasures intended to correct or improve conditions noted in the event and Prentative Action(s) are intended to prevent recurrence and address contributing causes. While RCA reveals and clarifies the line between a root cause(s) and an incident, this does not mean the incident was inevitable. The best way to take decisive corrective action is to understand your processes and act in a way customized to your organizational needs.
While the goals and basic principles of RCA always remain the same, numerous methodologies have been developed over the years to help problem-solvers determine root causes. Here are just a few that may be appropriate to apply to EHS incidents.
The 5 Whys. The 5 Whys technique was developed by Taiichi Ohno, who is perhaps best known as the father of the Toyota Production System that would inspire Lean Manufacturing principles. The premise is simple: When seeking the cause of a problem or error, keep repeating the question “why?” after each potential explanation. According to the theory, this method will usually reveal a root cause or defect within the first five times the question is asked. Naturally, this is not one-size-fits all—sometimes two whys will get to the heart of the cause, and other times it will take more than five.
Ishikawa diagrams. Named for its inventor, Kaoru Ishikawa, these are also known as fishbone or herringbone diagrams because of their shape. The “head” of the fish is the problem (in this case, an EHS incident). The “ribs” of the fish extend outward to the left and enumerate the major potential causes of the problem (e.g., employee behaviors, equipment, processes, and/or environmental factors). Each rib can then be subdivided into smaller and smaller branches listing more granular potential root causes to analyze.
Events (aka causal factor) analysis. This technique is primarily used for larger, single-occurrence incidents (such as an explosion or serious injury or fatality (SIF)) to quickly establish event-specific causes and timelines. While important for immediately taking preventive action against other high-risk, high-impact events, this technique may be less helpful for ongoing, broad application across EHS initiatives.
Change analysis. If you’re noticing a sudden uptick in incidents or another unfavorable shift in EHS metrics, there’s clearly been a change somewhere in your processes or in employee or management behavior driving it. Change analysis encourages leaders to backtrack and analyze organizational changes that preceded the drop in performance—and take steps to correct the issue.
Barrier analysis. Some incidents may come as a surprise because some barrier or other obstacle built into the work processes should have prevented the problem or detected it before the incident came to pass. Barrier analysis digs into what caused this guardrail to fail when it was needed.
There are, of course, many methodologies besides those listed above, many of them proprietary, such as TapRooT® RCA, or software-based in nature, such as Dakota Software’s Scout RCA. Scout includes a “Comprehensive List of Causes” workflow, which uses conditional check boxes to guide investigators through a list of causes starting with higher level actions, conditions, personal factors, and job factors.
There are many events that could call for a root cause analysis and your organization may utilize more than one of the techniques depending on the nature of the event. For instance, 5-why may be utilized for a simple near miss while the more intensive Ishikawa may be used for an injury or environmental release. Here are some common RCA triggering events and considerations:
Injury or illness. This is the most obvious impetus for RCA. Any safety incident should be thoroughly investigated, properly reported, and root causes determined and analyzed in order to minimize or eliminate future risk.
Environmental releases. Any harm to the environment should be investigated, reported, and analyzed just as rigorously as incidents threatening human health and safety. RCA can help determine flaws in systems and processes that may have allowed a release to happen and ensure it does not happen again.
Near misses. Don’t just shrug off a near miss—it’s an opportunity to ensure that in the future the potential incident will be prevented entirely. Proactively applying RCA methods to near misses will help.
Audit results. Did your latest EHS audit reveal issues with your systems, behaviors, management, and/or processes? Apply RCA to get to the bottom of these issues, and look for improvements in future audits of performance.
Regulatory requirements. For some industries, it’s required to perform thorough, regularly scheduled analyses of any risks facing your systems and processes (for example, if your organization is covered by process safety management (PSM) requirements). This may include identification of root causes, and the steps your organization is taking to prevent them.
To have the greatest impact, EHS leaders must utilize technology to track and learn from RCA investigations and target their CAPA efforts. Ideally, this technology should establish a foundation of EHS compliance, help to manage and collaborate on RCAs, and provide quality employee training (insufficient training is often revealed to be a root cause of EHS incidents). When utilizing a comprehensive EHS software program, you can be confident that its tools for incident investigation and RCA will be fine-tuned to improve safety performance companywide.
Need help? Dakota Scout can help you track and learn from safety issues, get to the bottom of health and safety incidents, and close the loop on the resulting corrective actions. View a demo of Dakota Scout here.