All of us who have been in the EHS business for any period of time have either led or participated in a root cause analysis (RCA). Too often root cause analyses morph into the proverbial root blame analysis. We sift through various aspects of an incident until we find someone or a group to blame, declare victory, punish the culprit, and have hand-wringing sessions over what to do to “fix” the supposed “root cause.”
Typically management labors over various reports on the incident; they feel good because they are addressing the safety of their folks. Another downfall of RCA is the use of the tool to always look “down” into the organization and not “up” — where more often than not the “Root” of the root causes is found.