Resources for Root Cause Analysis – What is Reasonable?

Something for Nothing?

Everybody wants something for nothing. This can be true when management assigns an incident investigation and root cause analysis to be performed by a supervisor in their “spare time.” In fact, I think the most common incident investigation (the minor incident investigation) is usually assigned to untrained supervisors who perform the investigation in their spare time. Is this a reasonable allocation of resources for root cause analysis?

What Do “Spare Time” Investigations Look Like?

Let’s say that a company had a near-miss that didn’t cost anything. No one was seriously injured. Therefore, management assigns a supervisor to do a quick investigation without looking into the problem in too much detail. The supervisor recommends re-training the employees that were involved. The training is conducted three days later. The investigation is completed, and the case is closed!

What is wrong with this investigation?

The root cause analysis failed to identify the true root causes and failed safeguards that caused the near-miss. The corrective actions (re-training) are very weak on the hierarchy of corrective actions.

The potential root causes of a bigger accident are never fixed. Sometime later, a major accident could occur because the true causes weren’t effectively addressed. People could be injured or killed. Large costs occur that are not covered by insurance. And what about OSHA fines (OSHA could call it a willful violation because previous incidents were not adequately addressed)?

What do you think? Did the company get something for nothing by assigning untrained investigators to perform a root cause analysis in their spare time?

Common Results of Spare Time Investigations

The results I hypothesized above aren’t unusual. Here are the results I normally see from “spare time” investigations:

• Poor investigations & corrective actions
• Repeat incidents
• Increased risk of big accidents
• Risk of regulatory action after a big accident or because of repeat incidents
• Increased liability when plaintiff attorneys show that management didn’t respond to previous incidents
• Overworked, disheartened investigators
• Investigators trying to dodge investigation assignments
• Disenchanted employees who look at investigations as a waste of time
• Inaccurate investigation statistics
• Loss of management’s faith in root cause analysis

That’s not what most companies want. Time to rethink “something for nothing.”

One key to a world-class incident investigation and root cause analysis program is to spend time identifying which “small incidents” are worthy of a good investigation because they have the potential to prevent major accidents. These near-misses of a big accident (precursor incidents) should be treated as seriously as the big accident itself. It deserves a thorough investigation, management review, and implementation of effective corrective actions to prevent the recurrence of the causes (and, thus, the big accident that’s waiting to happen).

So what does it take to perform a good incident investigation and root cause analysis? Read on to find out.

How Long Should an RCA Take? What Resources Are Required?

If investigating incidents in a supervisor’s spare time is bad, what is a good allocation of resources for a root cause analysis?

We might call it a measured response with a wise allocation of resources for root cause analysis. But what resources are required for an incident investigation and root cause analysis? How long will an investigation take?

It would be great if we could specify an absolute number. But the time and effort required for an investigation vary greatly depending on the size and complexity of the incident. However, we can start with three typical examples.

The Simple Incident

Start with a SIMPLE INCIDENT. A simple investigation by a single investigator is adequate (unless something unexpected is discovered). The key is that the single investigator has to be trained and has to have the time to perform an investigation. Thus, this isn’t an investigation in the investigator’s “spare time.” You must relieve the investigator of his/her normal duties for a period of time. How long? A day or two for most simple investigations performed by trained investigators.

The Major Investigation

Next, let’s look at MAJOR INVESTIGATIONS. Management seldom tries to have these performed in the investigator’s spare time. But, investigators are sometimes pulled away from the investigation to attend to their “normal” work.

In this case, a full-time investigation team needs to be formed with an independent facilitator, a full-time team leader, an adequate team (some full-time, some part-time subject matter experts), clerical support, contractor support (specialty analysis and investigation support), and perhaps legal and public relations support. The size of the team and the duration of the investigation depends on the complexity of the accident and the investigation depth requested by management.

A typical example would be five people working full-time for a month or two. Of course, I have seen complex investigations take much longer.

In Between Investigations

In between these two extremes lies the MIDDLE GROUND: investigations that require more than a single investigator but less than a full-blown team investigation.

The size of these investigation teams should be based on the incident complexity and the expected return on investment of the investigation. Thus, management needs to provide dedicated resources that are proportional to the work and benefits.

An estimate of a middle-sized investigation is three trained investigators/technical experts for a couple of weeks, with additional support if needed.

Management Approving Resources for Root Cause Analysis

For management to assign the appropriate resources, they must know the work required or have an investigation rule of thumb. Unfortunately, many managers haven’t performed a detailed root cause analysis, and- because the work required for different investigations is so variable – there isn’t a “one-size-fits-all” investigation guideline for the work required.

This means that management will have to start by assigning their best guess as to the required team size and then rely on the investigation team leader to request more support if needed. This won’t happen if team leaders are penalized for asking for help.

What does management need to do? Management needs to keep asking, “Is there any help that you need?” And then get the resources assigned.

Management also needs to make sure that investigators, team leaders, and facilitators are well-trained in advanced root cause analysis before they are assigned to perform an investigation.

As management sees the results of well-staffed investigations performed by well-trained investigators, they should start to have a feel for the resources that are required and feel confident that they are providing the resources needed for effective investigations.

One way to make managers more confident about their decisions is to hold an Executive Leadership’s Role in Root Cause Analysis Course for them. Find out more at THIS LINK.

Continuous Training, Grading, and Benchmarking Resources

Training investigators and staffing investigations is not a “one-and-done” effort. What continuing efforts are required? Read on…

First, investigators who are initially trained in advanced root cause analysis need feedback on their performance and continuing training.

FEEDBACK: The best feedback is to grade investigators’ root cause analyses. Where can you find out more about grading investigations and providing feedback? Start by reading THIS ARTICLE.

Also, we can help with grading and providing feedback when you first implement your program. Get more information about this HERE.

To continuously improve your investigators’ skills, they will need advanced and continuous training. This may include our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training or our 1-Day TapRooT® Refresher Training. To see our public root cause analysis courses, CLICK HERE.

Contact one of our TapRooT® Implementation Advisors to help you design your initial and continuous training efforts (CLICK HERE or call 865-539-2130).

Also, your key investigation facilitators and team leaders can greatly benefit when they attend the Global TapRooT® Summit. Get more information about the Summit at THIS LINK.

The Summit is a great place to benchmark your root cause analysis efforts, including the resources you assign to investigations compared with industry leaders from around the world.