3 Things You MUST Do When Finding an Incident’s Root Causes?

Hello and welcome to this week’s root cause analysis tips column. So what are the 3 Things You MUST Do When Finding an Incident’s Root Causes?

• You must know WHAT happened before you can determine why.
• You must know WHY before you can write corrective actions.
• You must FIX the root causes.

Let me elaborate:

You must know WHAT happened before you can determine why.

Too many investigators try to jump ahead and try to determine why things happened in an incident. But until you have all the facts, this is premature, and can lead to missing important data and letting the investigator’s bias drive the rest of the investigation. In the beginning of your investigation, you want to understand what happened. This is why evidence collection is so important.

Remember the old TV show Dragnet? The star of the show, Joe Friday, had a famous line:

“Just the facts, Ma’am, just the facts.”

Once you understand the facts, you can then move to why.

You must know WHY before you can write corrective actions.

If you do not have good evidence you will miss causal factors and root causes. Your root cause analysis results are based on two things; the evidence you collected, and the guidance in the Root Cause Tree® Dictionary. If you do not have both, you do not have a strong case.

This is actually the easy part of TapRooT®, because the dictionary is all based on research.

Last but not least, you must FIX the root causes. Your corrective action has to specifically address the root causes, has to be implemented, and has to be verified.

How many times have you seen a corrective action that has nothing to do with the root cause? The Corrective Action Helper® has a check at the beginning of each section to make sure you are clear on what you are fixing. It does not matter how good something sounds, it has to directly apply to the root cause it is fixing. Otherwise it is extra work for no gain. And it likely means another investigation in the future.

And of course, it has to be implemented. Do you have a way to follow-up to make sure? And do you have a plan to judge the effectiveness?

Corrective actions are the OUTPUT of your investigation. Good investigations with weak corrective actions are a WASTE OF TIME.

Hopefully this gives you some things to think about. Thanks for visiting the blog, and if you want to learn how to do good investigations, join us at a future course.

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