Kelvin TOP-SET includes Root Cause Analysis (RCA) as a key step in its comprehensive Incident Investigation process. The RCA comes at the end of the investigation, when the report is being written and recommendations formulated.
We review many investigation reports, as it’s one of the services we offer companies throughout the world. (This service is confidential, of course.) All too often, RCAs are missing from these reports, which begs the question: are they needed at all? The short answer is ‘no’, but the long answer is ‘yes’. A well-written report that describes the incident succinctly, and clearly identifies all the contributing factors, along with appropriate recommendations, does the job, there’s no doubt about that. But, an accurate RCA does so much more to enhance the quality and effectiveness of an investigation report.
So, what are the features of an RCA that make it so valuable?
1. Shows Proof of Logic
Take your mind back to school when you were given a mathematics problem and asked for the answer. Perhaps you were lucky enough to copy the correct answer from a clever neighbour! But trouble followed, because you were then asked how you reached your answer – the working was required, the steps in the process. It is the same with RCA. You know what happened, and you have a good idea of the root cause(s) of the problem, but RCA forces you to link the start and the finish with a series of logical steps that prove the root cause is linked to the incident itself. Plus each step is backed up by your sources of evidence so no one can refute your conclusions.
2. Tells a Story
The ultimate test of a high-quality RCA is that you should be able to hand it to someone without explanation or embellishment, and by reading it, they should have a clear picture of what happened, with all the factors that contributed to the incident linked in a logical way. So, a good RCA acts as an abstract or summary of the incident, and relieves the time-poor reader of the tedious task of reading the entire report, which usually amounts to many pages.
3. Paints a Picture
A good RCA is like a canvas on which an artist works. The team can look at it, viewing all the factors that contributed to the incident, linked in a logical way. They can discuss and debate the merits and demerits of each possible remedial action, and decide which deserve their attention. And remember, any Post-it in this logical sequence will offer the potential for correcting or embedding a new control, barrier or defence.
4. Shines a Spotlight on the Investigation
The RCA is constructed at the end of the investigation, when you hope all the contributing factors have been identified and described. The great benefit of the process of constructing an RCA at this point is that it will very quickly become obvious to you if there are any flaws in the investigation. The RCA acts as spotlight on all aspects of your work, illuminating chinks in your armour, which must then be repaired.
In essence, a report with no RCA can suffice but, if you can incorporate a well-constructed analysis diagram, the quality of your report will be increased immeasurably, ultimately leading to better outcomes.
If you are interested in how we can help you with incident investigation and root cause analysis, please contact us.
If you want to know more about the TOP-SET rules for doing RCA, sign up for for the e-RCA e-learning course here.