Applying Root Cause Failure Analysis to Safety

“A problem well defined is half solved” 
     ~Charles Kettering

In my forty-year career in the paper industry, I spent two decades working in manufacturing facilities where I had job titles such as Plant Engineer, Shift Department Foreman, General Foreman, Production Manager and Plant General Manager. It’s not hard to see why someone like me would now be teaching safety leadership classes to leaders the world over: I have a lot of personal experience with the challenges of sending everyone home, alive and well at the end of the day. 

Still, I’ll be the first to admit I’m far from finished working my way up to the top of my personal learning curve on the subject.

Early on in my career I was trained in quality circles, process control charting and structured problem solving.  That led me to spend a week with W. Edwards Deming, where I learned all about his quality improvement principles, process control and problem-solving techniques. Later I was trained in Lean and Six Sigma processes. Eventually I became certified, and what I learned became the foundation for the next phase of my career, teaching and managing the certification process for Green and Black Belt candidates.  

When I finally retired, I found the opportunity to combine my experience – manufacturing, managing safety performance and process improvement – to the challenge of safety leadership.  My perspective on managing safety performance is different, maybe even unique: I see this as a process, to be continuously improved.

As a teacher, my job is to create understanding and competency in the use of basic leadership tools.  These tools include making deliberate workplace decisions on a daily basis about where to go, when to go there, and what you want to accomplish when you are there.  There are clear parallels between tools focused on process improvement and the tools I teach like Managing By Walking Around, Managing Safety Suggestions and Asking Darn Good Questions.  While process improvement and safety leadership terminology may be different, the concepts and tools that drive results are identical and basic to both.

A fundamental and critical technique in process improvement involves Root Cause Failure Analysis. RCFA for short. You might think RCFA is an incident investigation by another name, but when used for process improvement, it’s so much more than that.

Root Cause Failure Analysis

Every performance failure has a reason.  Various techniques exist to arrive at, and clearly define the root cause of a problem; they all include the basics of observation, data collection, analysis, solution implementation and results validation.  That kind of rigor and discipline is critical to effective problem solving, as it is necessary to ensure leaders avoid the trap of attacking symptoms of a problem.  

The RCFA process starts with the definition of the problem. One of my favorite quotes makes the point “A problem well defined is half solved”.  Credit inventor Charles Kettering with those words of wisdom.  Defining a problem sounds simple, but it’s often the trap!  

Leaders get visual signals and data on a continuous basis.  When performance fails to meet expectations, the “Why?” question always follows.  Very few leaders respond, “I don’t know.” Even when they really don’t know.

Fundamental to the RCFA is the discipline – and patience – to keep asking questions and, when you don’t know, keep asking until you find out the truth.

RCFA Of The Compliance Problem

One of the biggest safety challenges I hear from the leaders I teach is compliance: following all the rules, all the time. The injury records often show many injuries are the result of rule compliance failures.  

Looking back at my front-line leader days, dealing with someone not following a safety rule was a daily discussion.  I just assumed they made a bad decision.  In other words, the failure to comply with a rule was a choice made by my follower: no need to dig further. They knew the rule, were experienced, and knew better. My discussion would focus on the disciplinary consequences in play.  

I suspect this routine sounds all too familiar.  As a leader, my understanding of the implications of consequences in terms of personal values came much later in my learning curve. As a young leader I was consumed with work and results.  It took an accident to understand work as a means to an end – family and loved ones – not an end in itself.  

If we’re honest about achieving some degree of wisdom, you recognize it arrives as hindsight. When it comes to safety, it’s a disappointing reality. Now I have the tools and some degree of wisdom; one fundamental tool is the RCFA process.

When teaching, whenever I ask why getting everyone to follow all the rules all the time is such a tough safety challenge the energy level among leaders peaks quickly. In their view, there is no shortage of reasons! 

But in compiling the list of reasons, the feedback always settles on four fundamental requirements; know and understand the rule, remember the rule, recognize the rule applies in the situation, and, finally, choose to comply with the rule. 

For anyone to follow any rule all four requirements have to be met.  The next logical question is, when you think about all the challenges we have with compliance, where do you think most compliance failures will fall? The quick response from leaders is the fourth reason – Choice!   That may well be the case, but now the thought process gets really interesting.  

Digging Deeper Into The Problem

The principle of Root Cause Failure Analysis is to keep digging until you understand everything, not just the symptoms. You do that by asking more questions.

See what I mean about time and patience?

I ask leaders to revisit their list of reasons why getting everyone to follow all the rules all the time is such a challenge and assign one of the four requirements to each challenge.   The breakthrough thought process starts to unfold.  Yes, choice often makes up half of the reasons; what about the other three reasons representing the other half?  When that’s visible to the leaders, the next question is: “What does the data tell us?” 

That’s what we call a Darn Good Question. The response is often, “See, we were right: most of the reasons fall under choice”.  

Next question: “What else is the data telling us?”

Silence. After a few moments, the lights start to come on!  

Choice may make up 50%; the other three reasons also make up 50%!  More significantly, the first three reasons are preconditions for making the right choice. Even more significantly, who controls the process of  knowing/understanding, remembering and recognizing situations?  

The leaders!

Leaders own all three.  Only when those are in place can followers make a good choice.  

The Learning Curve

Most leaders think the best they can do is influence the decision process their followers go through in choosing whether or not to comply with a rule.  In practice, leaders control the primary factors which are the preconditions for compliance!  

Taking it one step further, leaders control their leadership practices.  One of those practices is setting expectations. Leaders can help their followers understand the consequences associated with their failure to comply with the safety rules.  The consequences that have the most leverage in the workplace – as well as at home – are those that impact personal values: what matters most to followers. 

That means reminding our followers why they got up and came to work today.  For most of us it is to take care of our family and loved ones.  

I’ll be the first to admit it took me a long time to learn that simple and powerful truth. That was my learning curve; it doesn’t have to be yours.

In hindsight, my tendency was to focus on consequences in terms of disciplinary action.  They’re always on the table; in some cases they need to be used.  But the consequences associated with disciplinary action are only in play when the leader is present and followers are working. Followers often make most decisions throughout the day on their own, in the absence of their leader.  

The best leaders are constantly working to bring the powerful message of consequences in terms personal values into the thought process of their followers.  That consequence – the risk of getting hurt – is in play independent of their leader’s presence.  Leaders control delivering that message.

The Bottom Line

Root Cause Failure Analysis is a very effective tool in process improvement and can be equally valuable to managing safety performance, as this exercise in analyzing the challenges associated with compliance shows.  

Only when a leader has validated that their followers know and understand the rules, remember the rule and recognize the rule applies in the situation are they equipped to make the right decision. Assuming those three conditions are in place runs the risk of addressing nothing more than a symptom of a compliance failure.

If the assumption proves wrong the predictable outcome will be another failure and the outcome of that wrong assumption may well be out of the leader’s control. 

Bill Wilson
April 2022  

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