How and why, in a vacuum, are three-letter words. Add a question mark after each, and they could become the most confusing or convulsion-inducing words in the English language.

It is often, not just in safety, that “how” and “why” questions can be the most difficult to answer. They usually are the kinds of questions that involve figuring out motivations for someone doing what he or she did – and as we do not have the ability to read another’s mind or his or her heart, we can only rely on whatever evidence we can gather to try to understand a motive to accurately answer these kinds of questions.

[Image courtesy of Flickr user Jan Tlk via a Creative Commons license]

[Image courtesy of Flickr user Jan Tlk via a Creative Commons license]

Fred Manuele wrote a thought-provoking piece in the May 2016 issue of Professional Safety magazine which went into detail about answering the two most important questions in any incident investigation – how the incident happened and why it happened.

While in some way it could be easy to answer these questions, when you take out the politics of the worksite and get to the unvarnished truth, that can be more difficult. Manuele refers to drilling down and getting to the real heart of the matter, which isn’t a single root cause as many investigative models seem to consider, but instead looking at a contextual approach that considers all the actions that led to the incident.

Symptom vs. Cause

Manuele agrees with Erik Hollnagel and Sidney Dekker, who have written extensively about how the concept of a root-cause approach to answering “how” and “why” questions is actually counterproductive to what is really needed to understand incidents and take the decisive actions necessary to mitigate future incidents.

The approach is not about a single root cause, such as what might be a “symptom,” but to look at all parts of  the environment that led to the incident. Manuele quotes some information from a couple of other papers, besides Hollnagel’s and Dekker’s works, that go into the specifics of a multiple-causal approach, which does not take a narrow view of the “flash point” that directly led to an incident, but understands that the possibility exists that it could be the management system may have flaws and demerits that basically put the worker in the position to have the incident.

Looking in the Mirror

That is the truth that many of us don’t want to face. How could we possibly blame ourselves or our company for failures that led to this incident? We never intend to put our workers in harm’s way; we always try to do the right thing so everyone can work safely.

This doesn’t have to be intentional; it can just be missing unintended consequences of a certain policy or not thinking it all the way through, or missing steps because of a thought they were “common sense” and thus could be implemented by everyone.

To truly address incidents and mitigate the impact on our future, we have to take that really hard look at the entire situation and be willing to accept the possibility that our own system might have failed the worker, and we need to be prepared to embrace the change that is necessary. We have to admit that we’re human and we can make mistakes.

A Confusing Standard

Did you know there actually is an international standard for root-cause analysis (RCA)?

Maybe you did, but is it worthwhile to know it? Is a standard really necessary if it’s too broad? Is it rather counterproductive, rather than useful? Might it be better to not have a standard at all?

The international standard for RCA is called IEC 62740:2015 and while it is helpful as a tool for knowing about RCAs and their importance, the standard’s overall value to the safety community is limited simply by its breadth and scope.

Standards are much more efficient and useful when they are specific and/or detailed. This particular standard is hampered by having virtually every RCA technique and system available. Why? This is simply because there has not been a generally accepted RCA technique that has been adopted. This standard, which was first introduced a few years ago, was reaffirmed last year, which means no real progress has been made in terms of establishing a specific standard.

The good news of this is, however, that RCA is not some new concept that is only being practiced in a few places – there is an international use for RCA all around the globe, and it seems that every place uses its own RCA tools.

Coming up in my next post, we’ll look into Manuele’s assertion of support for the Five-Why technique in incident investigation and how it might help us all get past the politics and really answer those two vital questions.