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.

An alternative

Systems thinking offers another perspective for dealing with complex problems; one that has a higher probability of avoiding unintended consequences and leading to lasting results. David Peter Stroh  provides an interesting framework for conducting an effective systems analysis.

 Stroh begins by setting four criteria that an effective systems analysis should meet:

1. Expand the context of the problem in time by considering both its earliest antecedents and likely future, and space by considering the views of stakeholders whose perspectives are often ignored or denigrated.

2. Illuminate the often diverse viewpoints of multiple stakeholders.

3. Uncover how the people who are undertaking or commissioning the analysis might be unwittingly contributing to the very problem they are trying to solve.

4. Show how critical variables have been changing over time.

A questioning mindset

To meet these four criteria, Stroh presents ten questions to facilitate the systems analysis.  Stroh’s questions address any complex problem. The following questions are presented in the context of a safety problem.

1. What has been occurring in the past that is related to the safety condition you want to explore? When describing safety patterns consider key variables that exhibit one or more of the following patterns over time: 1) Oscillations; 2) S-Shaped Growth; 3) Steeply Rising or Runaway Growth (e.g., Performance); 4) Flat Line or Zero Growth (e.g., Performance); 5) Gradual Decline. Below is a hypothetical example.

The company has shown a steady increase in the number of behavior-based safety observations being conducted and for quite some time has been experiencing a fairly significant improvement in safety performance, surpassing the desired safety performance.  But in recent months the company has experienced a precipitous decline in safety performance leaving the safety staff and management to wonder what is exactly going on.

2. State your definition of the safety problem by completing the following sentence, “Why, despite your best efforts, has this safety problem been happening?” This question is difficult to answer because the vast majority of organizations use lagging indicators to measure their performance.  And management either directly or indirectly interferes with allowing for honest dialogue among stakeholders to surface the reasons for poor performance.

3. What are the earliest safety antecedents (i.e., events, actions, policies, etc.) of the safety problem? Describe any previous attempts to address or solve this safety problem. Too often we get caught up in the belief that all we need to do is work harder at doing our current program and performance will improve. As Dr. Einstein once said, “Doing the same thing over and over again and expecting different results is the definition of insanity.”

4. What is likely to happen in the future if this safety problem is not solved?  What are the costs (i.e., financial and human) of not changing? When it comes to a safety incident that results in serious injuries, we fail to define the hidden costs that are frequently higher and more devastating than the cost of the incident. 

5. How would upper management view this safety problem?  Although Stroh does not have a specific question for this step, I would ask the question: What behavior is management projecting to the organization that could contribute to the positive or negative safe behaviors of those employees who run the risk of being injured at work?

6. How would stakeholders as shown below see this safety problem? 

Rarely in the evaluation of a safety problem are all internal stakeholders taken into consideration and as far as external stakeholders there is deafening silence.

7. What other causes are affecting this system — in particular those which are distant or unintended — does the system produce? You need to look beyond the obvious and consider activities going on within and outside the organization. For example, is a union campaign underway, is there an unusual amount of production pressure, is there an increase in attention by regulatory agencies, are employees disgruntled about wages or benefits, etc.

8. What part of the safety problem is internal to your work group?  What piece of this safety problem is manageable as it relates to your position? Here is where the safety staff needs to reach out to the work group(s) experiencing the safety problem and help facilitate a self-reflection exercise to surface what may be going on. This obviously needs to be done in a non-punitive fashion.

9. In what ways do you or your group create or contribute to the safety problem through what you or the group thinks, says (or chooses not to say), or does (or chooses not to do)?  From a facilitation standpoint, surfacing what people think, say, and do or don’t is an excellent starting point.

10. What is the apparent purpose of this system? What appears to be the outcomes of employees’ efforts?  In my 40-plus years of EHS experience, fortunately I have never met an employee who came to work to get hurt.  Understand what employees expect their efforts to work safely should result in. Understand what employees think management really wants versus what management says it wants.

 You might think this approach is more involved than a RCA. I would differ with you based on the many RCAs I have participated in. Plus, using the Stroh framework provides a far richer and
robust picture of what is actually going on in your organization.

1.  D.R. Stroh. 2006. Conducting an Effective Systems Analysis. Retrieved 07/30/16 from