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Root cause analysis (RCA) is a process designed for use in investigating and categorizing the root causes of events with safety, health, environmental, quality, reliability and production impacts. The term "event" is used to generically identify occurrences that produce or have the potential to produce these types of consequences.
Simply stated, RCA is a tool designed to help identify not only what and how an event occurred, but also why it happened. Only when investigators are able to determine why an event or failure occurred will they be able to specify workable corrective measures that prevent future events of the type observed.
Understanding why an event occurred is the key to developing effective recommendations. Imagine an occurrence during which an operator is instructed to close valve A; instead, the operator closes valve B. The typical investigation would probably conclude operator error was the cause.
This is an accurate description of what happened and how it happened. However, if the analysts stop here, they have not probed deeply enough to understand the reasons for the mistake. Therefore, they do not know what to do to prevent it from occurring again.
In the case of the operator who turned the wrong valve, we are likely to see recommendations such as retrain the operator on the procedure, remind all operators to be alert when manipulating valves or emphasize to all personnel that careful attention to the job should be maintained at all times. Such recommendations do little to prevent future occurrences.
Generally, mistakes do not just happen but can be traced to some well-defined causes. In the case of the valve error, we might ask, "Was the procedure confusing? Were the valves clearly labeled? Was the operator familiar with this particular task?"
The answers to these and other questions will help determine why the error took place and what the organization can do to prevent recurrence. In the case of the valve error, example recommendations might include revising the procedure or performing procedure validation to ensure references to valves match the valve labels found in the field.
Identifying root causes is the key to preventing similar recurrences. An added benefit of an effective RCA is that, over time, the root causes identified across the population of occurrences can...