Cause Assessment and Event Analysis
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
- 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
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"