Back in the early days of my career, there was a palpable sense of accomplishment any time we discovered *the* root cause of an incident. Since we usually did this as a group, nodding heads would look at each other and feel like “this is it, mystery solved”.
Oh, how wrong we were…
Even today, I still see people zealously looking for *the* root cause of an incident. And, more alarmingly, feeling perfectly content with labeling it “human error”, usually on the part of the injured person. To this I say: you’re missing out!
Are you wondering why? Enter my favorite incident of all time (yes, I have one, I’m a Safety Management geek after all): the sinking of R.M.S. Titanic on April 15, 1912.
From a young age, I’d been fascinated with the story, and, after watching the eponymous James Cameron film in 1997, I grew even more interested in why such a catastrophe took place. In the months following my three visits to the theater to watch the movie, I got my hands on all the classic books, such as “A Night to Remember” and “The Night Lives On”, both by Walter Lord, and read each a couple of times. At that point, I was already headed to a career in Safety, and I knew the story of the Titanic was teaching me valuable lessons.
The more I researched the Titanic, the easier it was to see that multiple factors resulted in its fateful impact with an iceberg and subsequent tragic loss of life. Notably, the ship’s life safety design, with far fewer lifeboats than needed, became the “straw that broke the camel’s back”.
Are you tempted to blame everything on the captain’s “human error”? After all, it was his choice that the vessel be traveling as fast as possible in an unusually heavy iceberg season.
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I’d think again, especially after watching Nigel Levy’s 2012 documentary “Titanic’s Final Mystery”. The primary thesis of the documentary is that weather played a critical role in obscuring the iceberg until it was too close for the ship to steer clear. Particularly, the temperature gradient between the air near the water and the air a few feet above caused a phenomenon known as “super refraction”, resulting in a mirage that effectively hid he iceberg from view.
I could easily go on about the Titanic’s many lessons, but I’d rather return to my primary point: however you slice it, every incident has multiple causes. And however tempting it may be, none of those end at “human error”. Well, not if you truly want to shift things for the better.
Once you identify failures in the management system, instead of focusing on individual mistakes, you’re well positioned to change in meaningful ways. And this is what you want, otherwise you’ll still see the same incidents, perhaps with slight variations, occur time and again.
A thorough Root Cause Analysis, aimed not at the actual outcomes but focusing on the potential outcomes, or potential severity, is most suited for this end. In that framework, each root cause identified is categorized based on its potential to cause harm, and then aligned with one or more elements of the management system.
You could align the root causes with the levels of the Hierarchy of Controls: eliminate, substitute, engineering, administrative and personal protective equipment. Or you could align them with top-level elements of an ISO 14001 management system: context of the organization, leadership, planning, support, operation, performance evaluation, improvement. Whatever your choice, make it count: choose alignments that make the most sense for the organization by leveraging existing structures.
And keep in mind my rule for follow up actions: all for one, and one for all. Each action should align with at least one root cause, and each root cause should have at least one action. A smart action. Rather, a S.M.A.R.T. action: specific, measurable, achievable, relevant and time-bound.
Until next time, keep digging until you find all the root causes!