Conducting A Root Cause Analysis: Incident To Final Report

Root Cause Analysis is vital to health and safety

Incidents can happen in the blink of an eye. And reporting these incidents helps to drive progressive change to a safer workplace. But what happens when the cause of an incident is unclear? A root cause analysis suddenly isn’t just appropriate. It’s crucial. And knowing how to conduct a root cause analysis is as important as knowing how to report the incident in the first place.

A Root Cause Analysis is conducted by following 6 steps, beginning with the incident report and ending with a comprehensive root cause analysis. Understanding each stage of the root cause analysis is vital for successful preventive action plans creation and implementation.

Root cause analysis, also known as RCA, is the investigation process following an incident. The incident may or may not have caused harm to a person or property. Incidents may not have occurred at all, but instead, someone reported a dangerous situation. Either way, a root cause analysis ought to find completion following any form of incident.

This article will discuss the steps necessary to conduct a root cause analysis to a successful end. Tracing the incident’s steps and following the reporting and root cause analysis process to the end, we will find many useful tips and tricks to help facilitate your company’s reporting processes. Let’s jump right into why we want to do a root cause analysis in the first place to get us going.

Why Conduct A Root Cause Analysis If There Is An Incident Report?

Root Cause Analysis is vital to understanding and mitigating risk.

It may seem duplicative, even counter-productive, to produce a root cause analysis report following a previously reported incident. And in a sense, it may be slightly repetitive, but this is no reason not to complete a root cause analysis.

The sole purpose of a root cause analysis is to determine all the factors that contributed to an incident’s occurrence. It is a proactive management tool used to serve the process of corrective action.

An incident report documents an incident. However, those who complete incident reports are often more involved in reactive management of an incident than proactive management of the event. It is merely the nature of the beast.

To perform a root cause analysis, step out of reactive and progress towards proactive incident solution management.

So, why conduct a root cause analysis? Couldn’t we take a different approach to the incident report? Sure, you could do it, but why complicate a situation where reactive management is vital in controlling further incident damage or injury? Often incidents require a certain amount of reactive action merely to contain a hazard, which is often best left to its own devices.

Maintaining a separate procedure for root cause analysis allows for a more focused approach to proactive incident management. It also evades the corruption of a reactive issue’s causal factors that may, in the heat of the moment, obscure the real root cause as to why an incident occurred in the first place.

6 Steps To Completing A Root Cause Analysis

Analyzing industry-specific responses to incidents, we find that a complete root cause analysis procedure is completed best with a predefined set of steps.  Wikipedia decomposes the RCA into four steps:

  • Identify and describe the event.
  • Establish a timeline from ordinary events to the incident event.
  • Distinguish between the root and causal factors.
  • Establish a causal graph connecting the root cause and the event/problem.

We believe that taking things to a more generalized, less industry-specific approach, and yet in more depth and detail, is appropriate. Here’s our take on completing a root cause analysis in most industries; see below.

  1. The Incident Report Analysis
  2. Determining Leading Events
  3. Analyzing Leading Conditions
  4. Documenting Further Witness Information
  5. Analyzing Completed Data Collection
  6. Determining Corrective Action 

The Incident And Report Analysis

Beginning with identifying an incident, we analyze the incident to determine its characteristics. The incident often finds presentation via an incident report, but there are many possible sources of information for the incident. For example, the RCA may generate following a customer complaint, risk management referral, or even a complaint presented by HR. No matter the source generated by the RCA, you have to start identifying the problem or incident. 

As many RCAs are generated following incident reports, let’s go a layer deeper into these reports. An incident report should include the following:

  • Administrative details
  • Incident information
  • Witness accounts and observations
  • Actions and recommendations

The information provided ought to include as much information as possible; however, if you perform a root cause analysis, the incident will have already been recorded in the report. Analyze the information provided and look for holes in the information. Try to find any omissions, which can sometimes be the case.

For more information on what to include in incident reports, please read our article: 12 Things To Include In An Incident Report (With 5 Tips).

Determining Leading Events

As you analyze the incident report, a story should start to form in your mind about how it occurred. Aside from acts of nature, most incidents have precursor events. It is the classic cause and effect scenario. And it would help if you determined said causes.

When an incident occurs, we can determine any events that could have avoided the incident itself if removed. 

Analyzing Leading Conditions

Although events that lead up to incidents are apparent contributing factors, sometimes conditions are the prerequisites for incidents. At this stage in the root cause analysis, you should examine the conditions that surrounded the incident. Careful analysis of available data might reveal clues to establish the root cause or causes further. The information may also help us sort out the root causes from the other causal factors.

Documenting Further Witness Information

In certain incident types, witness information may require you to conduct a follow-up investigation. When analyzing the incident report data, depending on the nature of the incident, information might even be omitted simply by the assumptions of those involved at the time. Hindsight is 20/20, as they say.

Further witness information may include more than mere statements of those who were present to perceive the incident. The information may come from other forms of witnesses, such as the electronic sort. Incidents are often recorded using video surveillance equipment. You can use this to review incidents, and if there are any available other sources of information, you should collect and review them.

Analyzing Completed Data Collection

The fifth stage of the root cause analysis is analyzing the completed sets of data. It would be best if you had determined your leading events, the conditions surrounding and leading up to the incident, as well as any witness information. 

This stage of the root cause analysis requires looking at all of the data you have collected and reviewed. Determine the actual essential factors and events that led up to causing the incident. Separate the essential factors from those that are coincidental or only partially responsible. 

The simple way to accomplish this stage is to ask yourself if you removed that factor, would the incident still have occurred? Would it have been better or worse with that element removed from the equation? If the factor removed means the incident would not have happened, it is an essential contributing factor.

Once all contributing factors are organized, determining the root cause or causes of the incident should come naturally. And this drives us to the inevitable conclusion: how could the incident have been avoided?

Determining Corrective Action – The Final Report

Take a look at the root cause or causes you’ve determined during the course of your analysis. How could these factors have been manipulated to avoid an incident?

Most incidents are preventable. Whether you’re in security, manufacturing, medical care, or any other field, most of the time, we can avoid or prevent hazards from becoming damaging or threatening situations.

Analyze how preventing the incident could have occurred and document any possible and plausible solutions. For best results, document all ideas and eliminate them based on safety and feasibility. Using a methodology to brainstorm possible corrective actions, sometimes we can create a solution that exceeds what standard actions will achieve.

Your final root cause analysis report needs to be concise, comprehensive, and provide solutions. Preventable actions and strategies are always more effective than reactive actions. And you might be able to save someone from injury or worse.

Measures To Follow Through After The Root Cause Analysis

At this point, you’ve completed your RCA if you have followed the steps. But have you followed through on the recommendations? Has anyone completed corrective and preventive actions? The RCA becomes entirely pointless if nothing is done about the incident after all.

During the course of the RCA process, you may be asking yourself what the best method to try to determine the root causes is. Sure, it’s easy to say you need to figure something out, but how should you go about it? Is brainstorming the best option? If not, what is it? Let’s find out.

Root Cause Analysis Methodologies

If root cause analysis were a topic of study, it would be the study of cause and effect, with a major in investigative reporting. But many companies and organizations use a visual charting process as an effective means of communicating the root cause analysis. It is one of several methodologies used in the root cause analysis process. Let’s take a quick look at a few of the most efficient root cause analysis methods.

  1. Why 5 Analysis

The concept behind the ‘Why 5 Analysis’ is to ask the question Why, five times. For example, one might ask why did this car crash. The answer might be because a left tire blew up. Then ask why that happened, answer and repeat. The concept is to ask the question multiple times to keep diving deeper towards the problem’s root.

Although this method is brilliant in its simplicity, it also happens to be its curse. Many have argued that this method simplifies situations that you should not simplify. The method may inadvertently miss individual branches of thought by misdirection.

During the “Why 5 Method”, if the second “why” results in an answer that starts to lead away from the actual root cause, the domino effect of such a consequence could potentially skew results.

Due to the potential for misleading discrepancies, the “Why 5” method is best used in parallel, multiple times for a single incident. One may also determine that branching in our question chain is not only possible but often quite or even more probable than the assertion that a singular cause is at fault.

  1. Pareto Analysis

The idea behind the Pareto analysis is the Pareto rule. That is to say that eighty percent of the effects come from twenty percent of the causes. Another way of looking at the Pareto analysis method is to equate the methodology to a looking glass.

A looking glass, or magnifying glass to use a more common name, will take a small area of view and enhance it by presenting the small view on a larger scale. The concept of the 80/20 rule is similar.

The Pareto analysis breaks data into percentages of observations and then is represented graphically. Concurrently, Pareto analysis represented graphically is likely best left to massive data collection types of root cause analysis. This form of analysis uses a statistical-based methodology to conclude. Therefore, it may only be relevant for specific RCA applications. 

  1. Change Analysis

Change analysis methodology for root cause determination finds credibility in situations involving evolving events or conditions. For example, analyzing the change in roadway conditions over time may allow for determining a root cause when it pertains to a single-vehicle car accident. Or perhaps a facility records notes of equipment conditions over time, and the change of these conditions is analyzed. The idea is that the conditions or events that evolved are analyzed using this method of determining the root cause of an incident.

  1. Brainstorming

Our most basic and one of our most potent methods for root cause analysis is brainstorming. Because of its power, this method is the one method described in the six steps of conducting an RCA, as mentioned earlier.

The brainstorming method allows freedom of thought to attempt to determine the possible root causes of an incident. Using rough brainstorming followed by a sort of elimination period is one of humanity’s best abilities. It uses the best of our creativity and real-world experience. The downside is that brainstorming can sometimes end up being mono-directional, depending on the person’s mindset or persons involved in the brainstorming process.

Brainstorming Tip: When using the brainstorming method to determine the root cause of an incident, use a minimum of three people to help with brainstorming. This method works best when there are multiple perspectives to help come up with ideas. It also helps prevent mono-directionality.

Conclusions On Conducting Incident Report Based Root Cause Analysis

From the information you’ve read thus far, you must realize that the root cause analysis, as simple or complex a process as you make it out to be, has three primary goals.

  • To discover the primary root cause or causes of a problem or incident.
  • Next, to fully comprehend the nature of the incident and how it can be fixed or prevented.
  • To apply resolutions as a proactive management tool to prevent the repeat of the incident.

If these three goals find themselves met, then the root cause analysis may be considered a completed process.

Using an incident report as the basis for a root cause analysis is inherently wise from a safety process standpoint. Although, depending on the industry, it may find itself discarded. Take the medical industry, for example. Many hospitals are inundated daily with hundreds, even thousands of incident reports.

The truth is that as industry leaders, we each need to have a process that involves sorting incidents by the level of priority and thus obtaining a resolution to the flood of incidents. If the most severe face triage to a root cause analysis, there may be the hope of achieving a successful reporting system after all.

In most industries, the hope is that there are nowhere near the number of incident reports filed as there are in the healthcare industry. Most businesses shy away from adding further paperwork to their plates, and for a good reason. But, there is a solution to the paperwork dilemma regarding incident reporting and root cause analysis.

Using a digital solution like that offered by 1ST Incident Reporting is the solution to the seemingly never-ending paperwork. With digitally based incident reports, not only can you set up instant notifications, you can access reports previously completed with lightning speed. What better way to do a root cause analysis than have digital access to the incident report?


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