The title of this article is self-explanatory, but does it sound familiar to you? Does it strike a nerve perhaps? It might, but rest assured, we’ve all been there! So why does it happen?
Before we talk about why you might experience this issue, let us start with the good news: the fact that you have the data to tell you this means you are already better than most companies.
After all, no one has time to fix everything, so the only way you know what to focus on is to first collect the right data, and then have the ability to spot your problems in the data.
You are better than you thought, aren’t you? Now that you feel better, I have more good news: you now have an opportunity. An opportunity to fix your major problems and see your failures come down dramatically, and quickly. Exciting!
Armed with data in hand, you can get to work. In my view (and experience), there are two likely culprits that are to blame for repeat root causes:
First, you might be writing weak corrective actions. Attending TapRooT® training, using TapRooT® to help identify the right corrective actions, and then launching and tracking action plans from Enablon, which is integrated with TapRooT®, can address this.
A more likely issue, however, is that these repeat root causes are the result of what we call a “Generic Cause.” You might know this malaise by other names, such as System Causes, or Extent of Cause. The name is not important, the concept is. The TapRooT® definition of Generic Cause is:
“The systemic cause that allows a root cause to exist.”
Let me give you an example:
An employee makes a mistake while using a procedure. Upon investigation, you learn that there was a typo in the procedure. How would you fix that? Simple, you would fix the typo and republish the document.
But what if typos were among your top root causes? You would likely find that there are typos in many procedures, and this was causing different types of incidents. Fixing that would require understanding what in your SYSTEM allows typos. If you fix that, this root cause stops appearing. Your numbers then go down rapidly.
There is a huge difference between one person making a typo on one procedure and your entire procedure system being broken, wouldn’t you say?
In closing, always consider Generic Causes when working with root cause and performance improvement programs. As I mentioned, this starts with good data and good trending. If you can get to the point where your generic issues start to melt away, you will know you’ve done a great job, and your life will start to get easier. It is not an immediate gratification, it takes time. I call it “pushing the boulder up the hill.”
Thanks for reading, and best of luck in your improvement efforts.
View the recording of our webinar with TapRooT® to learn how you can enable a human factors-based incident investigation lifecycle, and how the integration of Enablon and TapRooT® facilitates the tasks of incident investigators: