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BlueDragon Tip of the Week: Get Ahead of Your Events; the Proactive Use of Causal Analysis.

There are two quotes that organizations should take more seriously. The first and lesser known of the two is attributed to the Dutch philosopher Desiderius Erasmus, from the 1500's: "Prevention is better than cure." The second and more famous quote is from Benjamin Franklin, who famously advised fire-threatened Philadelphians in 1736 that “An ounce of prevention is worth a pound of cure.”


We can all agree that it is more advantageous (and cost effective) to take steps to prevent issues from happening in the first place, rather than taking corrective actions after the fact. However, for some organizations, getting ahead of the game has not been so easy.


What does it mean to get ahead of events, and how can we do so? It means we must have a method to monitor and document performance gaps so we can tell where things are not working as well as they should; "hot spots" in the organization that are experiencing recurring issues. Once we have such as system in place, we can trend and analyze the data with the goal of early identification of negative performance trends. At many of the facilities that I support, there are negative performance trends in several key areas. Here are just a few examples.

  • Trends of low-level personnel injuries.

  • Trends of low-level vehicle accidents.

  • Trends of Work Control Program implementation issues.

  • Trends of Procurement Program breakdowns.

  • Trends of loss of control of Subcontractors.

Once we have a method that monitors and documents performance gaps and we are routinely trending and analyzing the data to identify negative performance trends, we can take the next crucial step: to launch an apparent cause evaluation or a root cause analysis that will uncover the deepest-seated causes for those negative trends.


The fundamentals of root cause analysis tell us that the reason those root causes are only causing low level events, is because we have sufficient defenses in place: administrative requirements (i.e. programs, processes, procedures) as well as physical barriers (lead shielding, fire doors, hard hats and safety glasses) that keep us safe and help prevent bad things from happening. However, because we have humans in the equation, it is only a matter of time before a set of negative variables line up (i.e. a perfect storm) and those same root causes find their way around all of our defenses and result in a major event.


By not trending the lower level events, organizations are missing a huge opportunity to proactively close the door on the root causes of significant events. Consider a site that documents 1000 low level performance issues each year. Of those, only 1 might rise to the level of significance that requires a root cause analysis. Perhaps 10% may rise to the level that requires an apparent cause evaluation. The remaining 90% are of low significance and are simply corrected and forgotten. If we could extract information from the 90% using quick-hit investigations, we would have the data needed to identify negative trends and proactively identify and address the causes. Organizations that are only investigating the 10% of issues that manifest themselves as events will remain in a reactive mode.


At one of the Department of Energy Uranium processing facilities, there was a negative trend of procurement issues where the site did not have critical spare parts in their warehouse when needed. The site was converting Depleted Uranium to Uranium Oxide, and the process was so delicate that, if a piece of equipment went down and could not be repaired in a matter of hours (i.e. a very short Limiting Condition for Operation), the whole operation had to be shut down. By analyzing the negative trend and mapping out the whole process, we identified the bottlenecks and the performance issues that were driving their problems. By taking proactive action on the negative trend, the facility addressed those issues, greatly reducing the potential for major shutdowns in the future.


Tip of the Week:

To get ahead of your events and drive your incident rates down, document performance gaps and conduct quick-hit (2-3 hr.) investigations of lower level events (not just the more significant events). Trend and analyze this performance data and identify negative trends (using Pareto Analysis, for example). Follow-up on any negative trends using formal investigations to uncover their deepest-seated causes, and take actions to close those gaps before they can result in any major incidents.


If you would like additional information on dramatically improving the effectiveness of your root cause analysis, visit us at: https://dle-services.com/bluedragon


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