01. Root Cause Analysis I Copy

Root Cause Analysis – Part I

Imagine you’re in charge of overseeing the smooth running of operations at a busy industrial plant. One morning, you receive a report of a plant worker who slipped, fell and suffered an injury on duty.

What’s will be the most probable action that you will take?
a) Involve HR to handle management of legal ramifications of on-the-job accident incidents, policy considerations for medical leave and expense coverage etc. Then, ensure all other staff are informed and assured via notices that urge everyone to follow safety procedures and protocols, and encourage them to get back to optimum productivity.

b) Order a detailed probe into the incident right away, to find out the exact chain of events that led to the employee getting injured. Speak to the injured person over the phone, interview eye-witnesses (if any) immediately and investigate in detail to ascertain if there was neglect of duty/protocol in any way.

c) Check with the floor supervisor if the injured person received timely medical intervention and assistance. Refer the case to HR. Make sure resource management is in place to counter the absence of the injured person who is bound to be on medical leave.

Debrief:
A) You’re being cautious about doing the right things and doing things right. That’s good. But aren’t you even a little bit curious about the details of the accident. How do you know there won’t be another accident the very next day?

B) Even though this option sounds a little excessive and time-consuming, it’s the right thing to do. You are right to be curious about the details of the accident. Employee safety is at stake after all.

C) You’re concerned about the injured employee. And you want to ensure business does not suffer any more that it must. That’s lovely. But aren’t you even a little bit curious about the details of the accident. How do you know there won’t be another accident the very next day?

The results of the detailed probe you ordered have come through. The report has all relevant details of the time of the incident and the observed cause of it. There was a puddle of oil on the floor, and the employee inadvertently slipped on it. You spoke to the injured person – it’s nothing serious, they should be able to resume work in a week.

Your interviews reveal no obvious neglect of duty/protocol by anyone.

Which of the following choices represents what you will do next?
A) File the report for records. Contact the facility management team and ask them to increase the frequency of cleaning/mopping on the shop floors. Communicate your findings to all employees via internal communications to assure them all is in order.

B) File the report for records. Contact HR and ensure the injured person is being extended all necessary support from the company. Send out a circular to all employees encouraging them to report oil spills when observed. Hold a review meeting with the affected team to discuss business continuity plans

C) Ask for more detail from the probe report. Why was oil on the floor? Who spilled oil, and then just walked away leaving it there?

Debrief:
a) Increasing the frequency of mopping/cleaning floors might help, but is that a foolproof solution? Would you not want to know why there was a puddle of oil on the floor? Where did it come from? Have there been incidents of oil slips before? If these questions are not answered decisively, you might find yourself having to go through this exercise again in the near future.

b) Your concern is duly noted, and you’d be very popular with your team. But are you convinced that the problem is solved? Would you not want to know why there was a puddle of oil on the floor? Where did it come from? Have there been incidents of oil slips before? If these questions are not answered decisively, you might find yourself having to go through this exercise again in the near future.

c) This option probably makes you feel you’re nitpicking, but you’re actually on the right track. You’re trying to determine what an oil puddle was doing on the floor. You might also be curious to know if there have been incidents of oil slips before. All good questions to ask.

The report now reveals that the oil leak wasn’t a result of human error; it leaked from a nearby compressor. The investigating team anticipates you’ll ask more questions, so they went a step ahead, checked maintenance logs and found out that this was not the first documented instance of oil leakage from the compressor. They have been tiny leaks noted on an off over the past few months. Also, regular maintenance checks for all machinery and equipment were happening on schedule every month. In any case, this was the first time so much oil leaked and the first time someone was injured because of it.

What would you do next?
a) Ask even more questions. If this wasn’t the first instance of oil leakage, why was the compressor not repaired earlier, during the scheduled maintenance checks?

b) No point asking more questions. Place a call and get the maintenance teams on the job.

c) Close the probe and file the report for records. Nothing very serious here – some amount of oil and grease around the place is to be expected in an industrial plant. Contact the facility management team and ask them to increase the frequency of cleaning/mopping on the shop floors, and have the facilities team schedule an additional maintenance check. Communicate your findings to all employees via internal communications to assure them all is in order.

Debrief:
a) Again, this sounds like nitpicking, but kudos on deciding to ask more questions. You’re better off getting to the bottom of this issue now, than figuring out that what you see is still symptomatic of a larger issue, and then having to return to the problem at a later date, by when it’ll probably be a full-blown crisis. It’s a good question by the way – if regular maintenance checks for all machinery and equipment were happening on schedule every month, why has the compressor been leaking oil for so many months? It doesn’t look like the compressor problem was ever detected – let alone fixed.

b) This option might eventually solve the problem, but are you sure you’ve gotten to the root of the problem? Because if you haven’t, and if all does not go well, you might have to return to the problem at a later date, by when it’ll probably be a full-blown crisis. Is it not worth asking some more questions to avoid that? For instance, if regular maintenance checks for all machinery and equipment were happening on schedule every month, why has the compressor been leaking oil for so many months? It doesn’t look like the compressor problem was ever detected – let alone fixed.

c) You can dismiss this issue as trivial at your own peril. All signs show that the problem is getting worse – tiny oil spills have now become a big oil spill that caused an injury at work. Increasing the frequency of mopping shop floors might be a stop gap, but there’s no way to guarantee that’s a comprehensive solution. Scheduling an additional maintenance check might help, but these checks have been happening on schedule every month, why has the compressor been leaking oil for so many months? It doesn’t look like the compressor problem was ever detected – let alone fixed.

Your suspicions were well placed. As it turns out, the compressor was not repaired earlier in the routine maintenance checks because it is not included in the residence maintenance team’s contract. The compressor is still under manufacturer’s warranty. As such, the maintenance team checked and where necessary, repaired every other machine when needed, but looked right past the compressor. And since there were no major problems with the compressor, no one noticed the oversight before.

You can now avoid wasting more time, and worst, a full-blown crisis by calling in the compressor manufacturer’s service team.

Bottom line: It is only when we know the root cause that we can take the appropriate corrective action. In the absence of such a study, we would be among the thousand hacking away at the branches, instead of the one striking at the root of the issue, to quote Henry Thoreau.

In the next section, we will explore the root cause analysis tool in detail.