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Root Cause Assessment and Event Analysis

"Not everything that can be counted counts,
and not everything that counts can be counted"……..Einstein

Doing a post-mortem on an incident that has significantly impacted your organization often seems like an unnecessary evil, as it takes some of your best performers away from their "real jobs" to understand why a "train wreck" occurred, to quote eminent root cause guru Dr. William Corcoran.

A well-done root cause assessment understands the underlying condition(s) and cause(s), initiating events, as well as mitigating and aggravating actions of the incident as the event(s) unfolded. A well done root cause also separates the symptoms from the condition, and forwards recommendations to prevent recurrence, thereby enhancing productivity, protecting the safety of workers, the public, plant equipment, and the environment.

We are sadly aware of headlines citing high-reliability required organizations that endured catastrophic failures or serious challenges:

  • Union Carbide Bhopal India 1984
  • NASA Challenger 1986, and Columbia 2003
  • Davis Besse 2002
  • Texas City 2005
  • Numerous hospital gas bottle misalignments
  • Flooded condenser floor: mis-aligned pump isolation valve
  • Electrocution: breaker not isolated
  • Workers suffocate: enclosed volume not tested
  • Serious back injury: fall protection not in place
  • Significant "near misses" in all work sectors

The list is extensive…..and when extended to daily incidents in organizations below the news "radar" . . . . . . seemingly endless.

Certainly finding the answers to what caused these events and others are important for preventing recurrence, and to provide closure. But even more important are the situations as they unfold where the opportunity to head off or prevent what could be a significant or catastrophic event poses itself. The ability of an organization to respond, evaluate and assess a situation could be the difference between being paralyzed, or finding and addressing the factors that led to the event.

The Apollo 13 situation was such an event. The safe return of its crewmembers was, as voiced by some, "would take some type of miracle." The reality for success was the leadership mentality that failure was not an option. The "cause and effect" evaluation performed by the spacecraft team along with the mission control center, came up with not just answers, but the right answers. Knowing your team possesses the skills and knowledge necessary to address and not compound the situation is a trump card when faced with a tough hand.

The predominant reason for doing a root cause on an event your organization has experienced is to understand the actions that led to a significant, or potentially significant event, to enable actions to prevent recurrence. "Close calls" should have root cause evaluations done for the same reasons.

At the WorkPlace Cornerstone Group we believe in learning, understanding, and addressing the root cause, and not chasing the symptoms. We have the expertise to conduct and/ or train your people in the discipline of performing Root Cause Assessments and evaluating Root Cause Assessments. We apply comprehensive root cause experience to enable your organization to identify the present and future pre-cursors in your programs, policies, procedures, and people activities to prevent or mitigate consequences of "unplanned" events.

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