Be Prepared for Not All Root Causes to Be Addressed

Be Prepared for Not All Root Causes to Be Addressed

You only need to think about some of the case studies in this book to recognise that ‘there's many a slip twixt cup and lip’ when it comes to achieving the goals you want, and this applies equally to agreeing and sustaining remedial action after an RCA investigation or inquiry.

Here is an account of an incident investigation that I was involved in where we could not agree on what seemed to be an ‘obvious’ action,

One of my clients had a serious health and safety incident involving two relatively inexperienced members of staff who were hospitalised because of underestimating a risk, combined with the fact that their supervisor was called away to attend to another urgent and important matter. Initially, the head of health and safety set up a team to look at what had happened, but the chief executive recognised a potential conflict of interest – after all, could a head of health and safety carry out a wholly unbiased and objective review in an area where the role and actions of the health and safety team were, potentially, something that needed to be considered? As a result, the Chief Audit Executive (CAE) was asked to get involved, and he contacted me to support the investigation.

The health and safety department led the investigation, but the CAE and I played a role in helping them ‘widen their horizons’ and capture what had happened (positive and negative). This helped explain a complex story relatively simply; it gave the organisation credit for many things it had done well while highlighting the ‘cracks’ that had let it down.

In summary, the RCA identified the following key facts and causes for the incident:

• Despite the temptation to blame the supervisor, given all the circumstances, there was no deliberate intention by them to cause any harm to the injured members of staff or neglect their work. Likewise, the members of staff involved thought they were showing some initiative doing some preparatory work ahead of schedule, but – for a range of reasons – this was unwise and triggered the accident.
• While the injured staff had been trained on health and safety basics when they joined the organisation, they should also have had refresher training through a new e‐learning course. This would have covered, in general terms, the sort of risk that led to the accident.
• However, the staff concerned had not done their additional e‐learning training at the time of the accident, although they had been reminded to take it by their depot manager. This happened for several reasons, including the workload of the staff and the fact that the depot manager did not have access to the e‐learning system to check what training had been completed by their team members.
• The question of who should check that staff had been trained resulted in an argument between health and safety (the policy owner), HR (who managed the e‐learning system) and the depot manager; a typical roles, responsibilities, accountabilities and authorities (R2A2) problem at an operational level.
• We also established that even if the staff had done the e‐learning training, its contents did not spell out, in detail, the scenarios that could lead to an incident.2 It also did not sufficiently explore which tasks needed to be ‘actively supervised’ by a manager (such that the staff should probably not have acted until their depot manager returned). And, while it's impossible to be sure, the CAE and I thought that the health and safety team would have been unlikely to identify this shortcoming in the e‐learning without some independent challenge.3

At the end of the investigation, five actions were proposed:

1. The creation of a framework for the implementation of the health and safety policy (i.e. the practical steps to make sure the policy would be operational) – a design and change management recommendation;
2. More explicit roles and responsibilities concerning the supervision of staff training and enabling depot managers to have access to the e‐learning training system to see who had been trained – an R2A2 recommendation, with a human factors aspect;
3. Manager targets to make sure their staff had been trained by a deadline – an information recommendation with a human factors component;
4. A new face‐to‐face training programme for managers and staff working in higher‐risk areas (to cover higher risks in more detail than would be possible in an e‐learning training) – another human factors recommendation, with resource implications;
5. Using the insights from the health and safety incident, we identified the need to improve the implementation of a range of other policies, e.g. data privacy, information security, etc. (where there was no e‐learning training at the time, nor timely tracking of training and staff understanding) – a change management recommendation with R2A2 and resource implications.

Actions 1–4 were accepted and implemented, with the additional face‐to‐face health and safety training requiring a substantial amount of time, cost and effort, but agreed upon without any significant resistance. However, regarding the wider learnings for other policy areas (point 5), we were told that although there might be broader lessons to learn, it was felt there was no ‘burning platform’ to justify these changes straight away.

At the time, I was somewhat taken aback by the decision to reject our fifth recommendation; but over the years, I have come to expect this when doing an RCA. No matter how ‘obvious’ it seems that broader lessons should be learned, decision‐makers will not always prioritise the issues you think are important. They have other challenges and priorities, and you should expect the outcome of an RCA and recommended actions to be subject to the same cost/benefit thought process as other proposals.