Avoid These Root Cause Analysis Mishaps to Drive Down Incidents

Every manufacturer is familiar with Root Cause Analysis (RCA), yet even with well-known methods in place, plant management can struggle to identify incident trends and pinpoint areas of improvement. While you can’t improve anything that isn't measured and analyzed, misguided analysis can have adverse effects on operations and prevent safety improvements necessary to produce high-quality products. 

RCA is a process of systematically identifying the root cause of an issue or incident, so that appropriate corrective and preventive actions can be implemented to avoid future occurrences. While there are several useful and effective methods for conducting RCA, the most commonly used method is the 5 Why's approach.

5 Why's

This problem-solving technique peels back the layers of "symptoms" by asking a series of “why questions” until identifying the root cause of an issue. Although simple, Continuous Improvement Coach, Sara Perrin, has seen why this technique can be problematic. 

“A lot of times, people will just blame the person – then you can’t get past that to find where there's a management system breakdown or things that leadership is doing that affects lineworkers' thought processes.”

Many in the industry have heard that over 80% of accidents are caused by behavior. But this statistic overlooks how that behavior is often shaped by work environment and processes. A simple example of the 5 Why's RCA analysis starts with Sara slipping on ice: 

When RCA looks like this, plant management is unable to come up with a solution for improvement, and the blame falls on Sara. It’s not uncommon for 5 Why’s to result in a “blame game” that impacts the company culture by eroding employee morale, and discouraging employees to participate in the next RCA.

When analyzing critical events, the goal is not to assign blame, but to prevent repeat occurrences. RCA teams need to assume positive intent, instead of entering the analysis with a negative view. This way, plant management can accurately understand the reasons behind behaviors that led to the incident.

Cause Mapping

One method that is often preferred by Sara Perrin is cause mapping. Cause mapping is similar to the 5 Why's approach but allows for branching out more, to get a more in-depth look at changes that can be made to prevent the incident from happening across the operation. This method encourages RCA teams to look beyond the immediate cause of an incident and explore all contributing factors. It also allows for a more collaborative approach, where different perspectives can be incorporated to identify root causes.

Taking another look at Sara’s slip on ice using a cause map, the catalyst for the incident isn't leaving on time but a larger production mistake. The holistic approach not only helps prevent future incidents but also promotes a positive company culture that values continuous improvement. Without corrective and preventive action, RCA can be inefficient and ineffective, leading to repeated incidents and frustrated plant leadership. 

In the food industry, conducting RCA regularly is a requirement to comply with regulatory standards. However, RCA should not just be viewed as a compliance requirement. It should be an integral part of a food safety and quality management system that helps identify and address potential issues before they become bigger problems. 

For more information on how a Root Cause Facilitator helps reduce incidents at facilities, listen to the discussion: Avoid These Root Cause Analysis Mishaps to Drive Down Incidents. Sara provides powerful advice and professional insights to refine RCA methods, the most common issues she’s experienced, and suggestions so teams will embrace RCA and work together to find solutions.