How to Create Effective RCA Documentation and Reports

Author: Rob De La EspriellaBD3, CEO and Founder, BlueDragon IPS

RCA Documentation Basics

Many organizations struggle with conducting thorough Root Cause Analyses (RCAs) due to a lack of effective RCA documentation and reporting. To identify and address the underlying causes of problems, RCA practitioners gather and analyze various reports and data.  From collecting evidence related to incidents to documenting procedures, hardware, software, costs, and the environment, each aspect plays a vital role in uncovering the root causes of issues.

This blog post will look into the crucial records and reports needed for an RCA and the importance of clear documentation. Also, how to effectively report findings to ensure successful problem resolution and the actions to prevent recurrence.

RCA Documentation: Gathering Essential Documents, Evidence and Data

The collection of evidence, records and other vital documents, organizing that information, and analyzing the data, are critical aspects of preparing for a Root Cause Analysis (RCA).  The RCA team collects witness statements, conducts interviews and takes copious notes, gathers procedures, collects data from databases and key performance indicators. Other inputs such as operator logs and equipment performance records are useful in evaluating equipment failures. Here are some tips on the kinds of RCA documentation that you can expect to gather and preserve during the RCA.

Fact Finding Sessions and Critiques:

 

In today’s fast-paced, information-driven world, the ability to effectively gather, organize, and analyze data is more critical than ever.  BlueDragon places a strong emphasis on the power of Fact Finding Sessions and Critiques, which are structured approaches to gathering and organizing information.  We recommend starting with the end in mind, using the BlueDragon chart to capture valuable information.

Key pieces of information you will need to identify during the fact finding sessions or critiques:

  • Timelines and sequence of events that explain what happened, when and where did it happen, how did it happen, and affected personnel. Do not discuss WHY it happened or seek WHO to blame.
  • The identification of applicable administrative requirements and how you can get a copy of those requirements. These will be included in our line of defenses.
  • The identification of any physical barriers that were in place but did not prevent the problem or event.  For example, personnel protective equipment, fire doors, shielding, etc.
  • The identification of any cyber barriers that were in place but did not prevent the problem or event.  For example, computer hardware, firewalls and other software applications.
  • The identification of additional sources of evidence such as databases and reports.  The following sections offer examples of the types of data that can be collected.
  • The identification of subject matter experts where we can go to find additional information and support.

Sources of Human Performance Data:

The following are examples of the types of information we should gather so that we can organize and evaluate as necessary.

    • Witness statements
    • Timelines (Sequence of Events)
    • Condition Reports
    • Work Control Packages
    • Emails and Other Correspondence
    • Operating & Turnover Logs
    • Key Performance Indicators
    • Trending & Analysis Reports
    • Physical Conditions of Work Areas (Photos)
    • Training Records
    • Self-Assessments
    • Human Performance Evaluations
    • Management Observations
    • Internal Audits & Surveillances
    • Independent Oversight Reports

Sources of Equipment Performance Data:

When investigating equipment failures or malfunctions, these are additional types of information we should gather to help us with our evaluation.

    • Physical As-Found Conditions (Photos)
    • Vendor Manuals
    • Equipment Maintenance & Surveillance Histories
    • Equipment Trending & Analysis
    • Reliability Centered Maintenance Reports
    • Equipment Fault Trees
    • FMEA Documents
    • Equipment Operating & Turnover Logs
    • Equipment Condition Reports
    • Equipment Operating & Maintenance Procedures
    • Drawings & Schematics
    • Operating Experience & Lessons Learned Reports

Occupational Safety and Health Administration (OSHA) Guidelines:

OSHA has published guidelines for Incident [Accident] Investigations that include checklists for preserving the scene and gathering information and evidence.  OSHA guidelines are useful as a guide for RCA documentation needed when conducting a root cause of an accident or incident.

You may download a copy of the OSHA guidelines HERE.

RCA Documentation: Organizing Essential Documents, Evidence and Data

Organizing the Information has always been a challenge.  Traditionally, the RCA team collects witness statements, conducts interviews, takes copious notes, gathers procedures, operator logs and equipment performance records. This jumble of information creates a challenge in keeping things organized.  BlueDragon organizes all this RCA documentation on a single virtual white board, creating a clear picture that can be more readily analyzed.  The sections of a BlueDragon chart are laid out in logical fashion so you simply need to follow the chart to understand what is needed for the RCA or investigation.

Typical Sections in a BlueDragon Chart:

  • Administrative section: Problem statement, team composition, acronyms, etc.
  • Systems Inventory: Using concepts from Systems Theory, we take a holistic approach to the RCA.  The RCA practitioner should determine what subsystems or elements are involved in the successful operation of the functional area where the event or problem occurred.  For example, for a maintenance event, they should find the programs, processes, procedures in place to ensure that the maintenance activities are conducted safely and effectively.  These may include the company’s Industrial Safety Program, Conduct of Maintenance, Preventive and Corrective Maintenance Programs, and Work Controls.  By taking a holistic approach, the RCA will be much more accurate and the actions more likely to prevent recurrence.
  • Key Stakeholder Inventory: The identification of affected organizations, so that we can schedule focus groups with a representative group from those organizations.  Key stakeholders can be from the company or external to the company.
  • Data Analysis Section: Since the virtual white boards are infinitely large, we can add the completed analyses to the chart.  These can be Pareto charts, process maps, fault trees, control charts, etc.
  • Timelines: At BlueDragon we divide the sequence of events into multiple timelines, to develop a much better picture of what was happening in various parts of the organization. For example, separate timelines for the personnel actions, the work controls in effect, key milestones and company events, emergency response actions, etc.
  • Line of Defenses: This is a comprehensive list of the precise requirements, physical and cyber barriers that should have prevented the problem or event. The sum total of these defenses did not prevent the issues, we must determine which defenses were effective and which ones were bypassed, ignored or ineffective.
  • Lines of Inquiry Questions: Using the performance evidence and data analysis, we generate questions that will be used as lines of inquiry during cause & effect analysis.  Questions can be generated from any part of the BlueDragon chart that shows relevant data or information.
  • Causal Analysis Section: One we have analyzed all of the available evidence, information, reports and data, we take all the lines of inquiry questions and line them up in this section so we can conduct the cause & effect analysis.  The cause & effect sequences will all be captured in this section.
  • Corrective Actions Section:  After the cause & effect analysis has identified the root causes and significant contributors, the issue owners and the corrective actions for each of those deep-seated causes will be captured in this section.

RCA Documentation: Analyzing the Data and Documenting Results

 

Analyzing the evidence and data has also been a significant challenge.  One of the key issues is that there is confusion between data analysis and causal analysis. Both are essential to an RCA, but are conducted separately. First, we analyze available data and other relevant information and we extract insights from the data.  And second, we use those insights to conduct the causal analysis and identify the root causes.

In simple terms, if the tool or technique we are using is not conducting Cause and Effect Analysis, then it is data analysis.

Typical Data analysis tools used in RCA:

  • Pareto Charts
  • Fault Tree Analysis
  • Process Maps
  • Histograms
  • Control Charts
  • Statistical Analysis Charts
  • Barrier Analysis
  • Task Analysis
  • Change Analysis
  • Comparative Timeline Analysis
  • Risk Matrices
  • Organization Charts
  • Earned Value Management Charts

The results of the applicable data analyses is also captured directly on the BlueDragon chart and become part of the RCA documentation.

Data analysis gives us performance insights that help us generate lines of inquiry questions. With those questions, we can begin our Cause & Effect Analysis, which is the heart of the RCA process.  The generation of great questions is one of the most important elements of an effective RCA.

At BlueDragon, we stress the fundamentals of critical thinking to understand how to best generate great focused, evidence-based, unbiased questions.  And also which types of questions to avoid, such as accusatory questions, curiosity questions, and leading the witness questions (i.e. confirmation bias).

Fundamental steps BlueDragon takes to generate great questions:

 

  • Analysis of Defenses: A determination of the effectiveness of our line of defenses (i.e., applicable administrative requirements, physical and cyber barriers) and generating questions on deviations, non-compliance with requirements, or non-conformance with standards and specifications.
  • Analysis of the Timelines: Obtaining insights from the sequence of events and generating questions without duplicating those that were already developed from the Analysis of Defenses.
  • Insights from Data Analysis: Generating questions from the negative performance insights developed from analyzing data, such as Pareto charts, process maps, control charts, etc.

As Albert Einstein famously said: “If I had an hour to solve a problem and my life depended on the solution, I would spend the first 55 minutes determining the proper questions to ask, for once I know the proper questions, I could solve the problem in less than 5 minutes.”

RCA Documentation: Documenting the Causal Analysis and Results

 

Root cause analysis involves digging deep into the data collected to uncover underlying issues that may have contributed to the incident.  Once we developed our lines of inquiry questions, we continue with the RCA by conducting Cause & Effect Analysis with focus groups comprised of the organization’s Subject Matter Experts (SMEs) and external SMEs as needed.

Typical steps that go into the causal analysis phase of an RCA:

  • Conduct a Key Stakeholder Analysis to identify the SMEs that can answer our lines of inquiry questions.
  • Schedule focus groups of representative samples of SMEs from affected organizations, both internal and external to the company.
  • Avoid 1-on-1 interviews, since that allows individuals to steer or even undermine the RCA with their biases. Focus groups allow us to establish and validate the best answers.
  • Reserve the proper setting to conduct these focus groups, preferably in a neutral setting.
  • Begin by asking each focus groups the initial lines of inquiry questions that they are best suited to answer.
  • The techniques to conduct Cause & Effect Analysis are an enhanced version of the 5-Whys, which was developed in the 1930s for automobile manufacturing, and by itself, not effective in modern RCAs.
  • Here are the types of follow-up questions we can ask the SMEs to continue with the Cause & Effect Analysis once we get our first answer to the initial question, with the goal of continuing to identify deeper causes.
    • Add a WHY in front of their previous answer (paraphrase).
    • You can ask: and why is that?
    • You can ask: can you elaborate some more?
    • You can ask: why would you say this is happening?
  • We do not stop asking the questions until one of these two barriers are encountered:
    • They do not have an answer and we need to ask a different group of SMEs.
    • Their answer is a causal factor that is beyond the organization’s span of control. For example, the budget for the Department of Energy, which is approved by Congress.
  • Once we have asked all of our lines of inquiry questions to the SMEs from affected organizations, we will have uncovered the deepest-seated root causes for the issue being investigated.
  • If the RCA only uncovered 1 root cause, then the investigation lacked rigor (i.e. we did not generate enough lines of inquiry questions).
  • In modern complex work environments, it takes a group of deep-seated root causes to bypass our line of defenses.
  • At the base of the cause and effect analysis will be the deepest-seated causes and contributing factors, color-coded for any observer to be able to readily grasp the information presented.

The results of the causal analysis phase are captured on the same BlueDragon chart  and also become part of the RCA documentation.  This chart forms a comprehensive picture of the entire RCA, which is sometimes  called a “storyboard.”

RCA Documentation: Documenting the Corrective Action Plan

 

The traditional, most often used corrective actions issued after an event do not actually prevent recurrence.

Typical actions that do not prevent recurrence include:

  • “Reinforcing” or “clarifying” expectations
  • “Reviewing” procedures & processes
  • “Evaluating” or “researching” other options
  • One-time training, memos, briefings, tailgates
  • Disciplining, coaching or counseling of individuals

Also, empirical data from the Energy industry shows that more than 90% of all corrective actions are purely administrative in nature, which are not considered the most effective actions to prevent recurrence by the Hierarchy of Hazard Controls.

The BlueDragon approach is to help issue owners to develop sound corrective action plans that have a much higher likelihood of preventing recurrence.  To that effect, BlueDragon uses powerful strategies that dramatically improve the likelihood of preventing recurrence of the root causes and contributors.

BlueDragon strategies for effective corrective actions:

  • Lean Mistake Proofing
  • The Hierarchy of Hazard Controls
  • Extent of the (Root) Cause Reviews
  • Get Rid of Stupid Stuff (GROSS)

In keeping with the strategy to capture as much information on a single BlueDragon chart, the corrective action plan for the identified root causes and significant contributors also become a permanent part of our RCA documentation.

RCA Documentation: Exit Briefings and Final Reports

 

Exit Briefings: When briefing management, experience shows that presenting the overall chart on our virtual white board is the most effective manner to present results, rather than a exhaustive document or a Power Point presentation that simply goes over the RCA documentation.  Executive summaries and Power Point presentations do not have the same effect as a large display that captures the data that was analyzed and the cause & effect sequences that led to the root causes and corrective actions.

Final reports: These reports are generated directly from the final BlueDragon chart, which was validated by senior management during the final focus group. The report can be structured in a clear and concise manner by capturing the cause-and-effect sequences from the root cause at the bottom, describing in narrative form how the root causes led to the event by following the cause-and-effect sequences.

BlueDragon final reports are a concise representation of the RCA documentation that was captured every step of the way during the RCA.

Typical BlueDragon final report sections:

  • A brief introduction including a definition of the problem.
  • A 1-2 page executive summary of the root causes and significant contributors.
  • A short section that describes the client and its affected operations.
  • A short section that describes the BlueDragon system used for the RCA.
  • A section for each root cause, which also captures the contributing factors that led to the root cause.
  • A section with proposed actions and issue owners.
  • An Appendix to captures the rest of the administrative information:
    • A list of personnel that participated (by titles only).
    • A list of records and data reviewed by the team.
    • Short biographies for the RCA team members.
    • For Department of Energy clients, a table that cross-references the root causes to the DOE Cause Tree.

 

RCA Documentation: Tracking Corrective Actions

 

For effective implementation, tracking, and monitoring of solutions identified in the RCA, a structured process is necessary. Many organizations have a Corrective Action Program (CAP) where RCA results can be logged and the actions tracked to completion. The closure of these actions should be monitored to ensure they are completed on time and that closure documentation is acceptable and can stand up to scrutiny.

The information collected and stored in the organization’s CAP is also an essential part of the RCA documentation as it helps with the long-term tracking and trending of recurring issues and the effectiveness of corrective actions.

Trending RCA Documentation and Corrective Actions

 

With the plethora of reports and the RCA documentation gathered during the Root Cause Analysis (RCA) process, organizations can utilize this wealth of information for future RCAs. By analyzing and trending past incidents, trends, and causes documented in previous reports, teams can proactively identify potential issues before they escalate into major problems.

For example, the root causes and contributors can be assigned a CAUSE CODE, and these cause codes can be trended quarterly to determine if similar issues continue to occur. Recurring cause codes may be indicative of ineffective corrective actions.

This proactive approach can help in preventing similar incidents in the future and streamline the RCA process by learning from past experiences.

Continuous Improvement of RCA Processes

 

Improvement of RCA processes requires ongoing monitoring and updating of procedures to ensure effectiveness. For instance, regular reviews of RCA reports and tracking of implemented corrective actions can provide valuable insights into the RCA process’s success.

By continuously refining and updating RCA processes based on RCA documentation, feedback and results, organizations can drive continuous improvement and enhance their ability to identify and address root causes effectively.

Summary

 

This blog post provides a comprehensive guide on documenting the progress and results of your Root Cause Analysis (RCA). It emphasizes the importance of thorough preparation, including clearly defining the problem, gathering and organizing relevant data, and analyzing the information using various tools and techniques.

The blog outlines the crucial steps in preparing for an RCA, including collecting witness statements, conducting interviews, gathering procedures, and collecting and analyzing data from various sources. It recommends using a structured approach, such as the BlueDragon Integrated Problem-solving System, to organize information effectively on a single chart.  The blog also highlights the significance of analyzing data and documenting results. It distinguishes between data analysis and causal analysis, providing examples of data analysis tools like Pareto charts, fault tree analysis, and process maps. The results of these analyses are captured on the BlueDragon chart, which helps generate focused, evidence-based questions for the causal analysis phase.

The blog also highlights the use of lines of inquiry questions to facilitate a productive Cause & Effect Analysis with subject matter experts (SMEs) in focus groups, and outlines strategies for identifying and documenting the deepest-seated causes of the problem.  It also discusses the importance of documenting the corrective action plan using strategies like Lean Mistake Proofing and the Hierarchy of Hazard Controls.

Lastly, the post stresses how the final RCA results are captured on a single BlueDragon chart, creating a compelling storyboard. The chart is also useful in preparing a concise final report.

The content also stresses the importance of tracking the implementation and effectiveness of corrective actions, and maintaining records for future RCAs.  RCA records and effectiveness reviews help in continuously improving RCA processes based on feedback and results. By leveraging the wealth of information gathered during RCAs, organizations can proactively identify potential issues and drive continuous improvement and prevent the recurrence of issues.

For additional insights or questions about RCA or the BlueDragon Integrated Problem-solving System, contact us by following this link.

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About the Author:

Rob De La EspriellaBD3, CEO and Founder, BlueDragon IPS

Deming Prize winning team member and pioneering Nuclear Quality Assurance expert Rob De La Espriella draws from four decades of experience in the commercial nuclear power sector and the nuclear weapons complex to offer deep insights into Root Cause Analysis and Total Quality Management. Rob is a leading expert in solving complex human-centric problems in our modern work environments, and has re-defined how organizations solve complex problems with the BlueDragon Integrated Problem-solving System (IPS), the first universal problem-solving system that can be applied to all regulated industries.  Rob is a former nuclear submarine officer, a decorated Resident Inspector with the US Nuclear Regulatory Commission, and a senior manager at commercial nuclear power plants. He was also on the Florida Power & Light team that won the Deming Prize from Japan.  Since 2007, he has been a Senior Policy Advisor for the Department of Energy and their contractors, helping solve some of their most complex issues.  Rob is a adjunct professor at Endicott College in Beverly, MA, and in 2023, he was accepted into the Forbes Business Council and is a Forbes contributor.

© 2024 DLE Technical Services, LLC. All rights reserved.

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