Author: John Watson
Historically there have been two recognized causes of accidents; unsafe acts (human error) or unsafe conditions. More recently, accident investigation is being adapted to recognize that typically, the cause is more complex than a simple unsafe act or condition. Most serious losses are caused by multiple factors, which when carefully analyzed, normally point to a flaw in the management system of an organization.
In line with this new perspective in accident investigation, the traditional concept of root cause analysis (RCA)1 is being enhanced. Almost all accidents have a contributory and a root cause. For example, if a higher education employee is electrocuted because of a failure to lockout an electrical system, the contributory cause is the failure to properly de-energize the system. Too often, the investigation stops there, with a recommendation to retrain the higher education employee in the lockout procedure.
However, a good RCA will dig into the factors of why the higher education employee did not follow the procedure. A well-done RCA can often find the hidden flaw in the management system and fix not just that single incident, but also many others like it, enacting real change toward preventing future losses for your educational institution.
Benefits of Root Cause Analysis
- Add value to the organization
- Create the potential for cost reduction or improved allocation of resources
- Provide a learning process for better understanding of relationships, causes and effects, solutions, and ownership of risk
- Provide a logical approach to problem solving using data that already exists
- Reduce recurring risk
- Mitigate likelihood of similar losses
- Improve performance
- Support development of more robust and resilient systems
How Higher Education Institutions Can Use Root Cause Analysis
There are times when a “team” root cause analysis is called for. Examples of this type of root cause analysis might be when:
- There has been a significant event or loss such as a serious injury, death, or large property loss.
- There are repeated losses, e.g., multiple similar injuries in a work unit or job function, similar types of property losses across campus, and repeated accidents in a specific location.
- There is an awareness of repeated “near misses” which are leading indicators of a future large loss.
- An audit determines that required practices are no longer followed or are ineffective (e.g., training, reporting, and submission of credentials before being given access to facilities, programs or property).
- There has been a change in organizational risk appetite and past accepted loss levels must be decreased.
Risk managers may be in a unique position to organize the institutional effort to create a RCA task force. Loss patterns may be recognized through claims and loss data, campus police or Title IX reports, incident reports and other types of data analysis.
Who Should Be Involved
Participants in an RCA task force will depend on what is being investigated, but a typical higher education team would be composed of the following:
- Management responsible for and familiar with the area where the losses or non-compliance appear
- Higher education employee(s) who conduct the operation in question
- Risk Management
- Safety officer
- Internal Audit
- Legal Counsel
- Other campus personnel that might be beneficial: investigator from campus police, laboratory or research safety specialists, workers comp specialist, etc.
Root Cause Analysis Techniques
There are many different techniques used in performing RCA. Each higher education institution should use a method that best suits their needs, resources, and operational model:
- Ishikawa Diagrams (fishbone diagrams2)
- The 5 Whys3 Method
- Fault Tree Analysis4
- Failure Mode Effects Analysis (FME)5
Institutions that may need repeated RCAs, because of their size or other factors, can also easily find affordable training programs on how to perform RCAs by contacting your Broker, referring to the IIA website6, or reviewing scholarly articles available online.
Engaging in RCA following a serious loss will clearly benefit the higher education institution if the information is used to help prevent future losses. It can also benefit the school’s insurance program if the analysis process and the follow-up loss prevention practices are reported back to the institution’s insurers, creating a positive circle of reinforcement that the institution is engaged in improvement for the benefit of all.
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