Root Cause Analysis focuses on the direct cause of incident within the workplace .

By executing a root cause analysis, it allows you to eliminate or prevent the same incident from recurring again in the future. It also reduces the risks of death and injury within the facility and its surroundings. You can also avoid unnecessary costs such as auditing, regulation, inspections, response, and clean up.

Most importantly, however, by leading with an optimized process safety program that involves root cause analysis

Example (OSHA):

An oil puddle was found on the facility of the floor, and this had caused an accident.

Traditional approach: Clean up spill and instruct workers to be more cautious

Proactive approach: Conduct a root cause analysis to determine the direct cause of the spill, i.e., ineffective maintenance process or lack of a system that detects and prevents leakage.

The Root Cause Analysis Four-Step Approach

1. Identify and describe the problem

2. Determining the significance of the problem

3. Identifying the causes or actions through a timeline and surrounding the problem

4. Working back to the fundamental reason as to why this has occurred. This will be the endpoint of the assessment.

Root Cause Methods

a) Events and Causal Factor Analysis

b) Change analysis

c) Barrier analysis

d) Management oversight and risk tree (MORT) Analysis

e) Human Performance Evaluation

f) Kepner-Tregoe Problem Solving and Decision Making

Root Cause Tools

Brainstorming

Checklists

Logic/Event Tress

Timelines

Sequence Diagrams

Overall process including RCA

Phase 1 : Data Collection

Accurate information such as environmental, personnel, and other factors must be taken into consideration before, during, and after the incident. Areas that need to be highlighted are (1) activities that are associated with the occurrence, (2) the initial or recurring problems, (3) hardware or software evident, and (4) any recent contextual changes.

Phase 2: Assessment

This is where root cause analysis will be executed with the relevant tools and methods.

There are several cause categories according to OSHA, such as equipment/material problems, procedural problems, human error, design problems, training deficiency, management problems, and external phenomena (reference).

Findings will then need to be summarized and explained, as well as the causal factors and recommended corrective actions.

Phase 3: Corrective Action

The implementation of corrective actions is necessary to ensure that the problem will not occur again – improving reliability and safety. Methods should be used to determine the effective measures with consideration of the relative impact on the facility.

This should align with not only the company’s mission and vision, but the facilities’ commitments and other obligations. Management and employee cooperation is needed to ensure effective implementation of these actions.

Phase 4: Inform

Entering the report to the Occurrence Reporting and Processing (ORPS) system as data should be kept for future references. This includes corrective actions, involvement of management and personnel, and other factors that are considered necessary.

Phase 5: Follow up

A review of the corrective actions is needed to determine the effectiveness of these. The corrective actions should be tracked to ensure that they have been adequately implemented and are operating as required. Furthermore, a periodic review of the correction action tracking system, standard process, change control system, and occurrence tracking system should be executed.

If any recurrence of similar events had happened, this must be identified and investigated to determine why the corrective actions were not successful in stopping these occurrences. When this occurs, further assessments must be done to resolve this problem.

Reference

Occupational Safety and Health Administration (OSHA). 2016. “The Importance of Root Cause Analysis During Incident Investigation.” https://www.osha.gov/Publications/OSHA3895.pdf

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