Transforming Losses into Learning: Root Cause Investigation

In the world of risk control, preventing losses is a top priority. How do we achieve this? One way is through risk identification, analysis, and mitigation. Another critical approach is to extract every possible lesson from each claim or near-miss. If we can do that, we can implement real change that can reduce or eliminate future claims of the same type. The answer to all of this lies in conducting thorough and timely root cause investigations.

In our journey to define an effective process for our members, we reviewed several root cause methods. Ultimately, they all led to the same fundamental question: Why? Why did this happen? Why did the employee take certain actions? Why weren’t policies and procedures followed? Why wasn’t accountability established in the aftermath? Why, why, why! If we couldn’t sufficiently answer the why questions, it became clear that our investigation had not gone far enough—and this could lead to faulty conclusions.

To provide a streamlined yet effective process for our members, we developed a four-step approach to root cause investigation: document review, meeting preparation, site visit, and root cause determination. This framework is comprehensive yet user-friendly, ensuring that supervisors can handle investigations efficiently and effectively.

Step 1: Document Review
The first step is to gather and review all relevant documentation. This includes policies, procedures, incident reports, photos, videos, and police reports if applicable. Reviewing this information helps build a solid foundation for the investigation by identifying any discrepancies or gaps in protocols. Understanding what policies were in place at the time of the incident is key to determining whether deviations occurred. The insights gained from document review set the stage for the next steps and ultimately inform the root cause determination.

Step 2: Meeting Preparation
After reviewing the documents, the next step is to prepare for interviews with the employee involved in the incident and their supervisor. The goal here is to ask open-ended questions that get to the heart of why certain actions were taken. The questions should address the “who,” “what,” “where,” “when,” “how” and “why” of the incident. Meeting preparation is critical because it helps identify missing information and areas of concern. These conversations can provide valuable context, especially regarding why policies weren’t followed or what specific challenges the employee faced.

Step 3: Site Visit
A site visit is perhaps the most vital step in the entire process. Seeing the environment where the incident occurred and interacting directly with the employee and their supervisor often reveals insights that documents and interviews alone cannot. During the site visit, our first question is always to ask the employee to walk through the incident, explaining their decisions and actions step-by-step.

As the employee explains, what starts to happen is that they provide us with the “why” behind their actions: “I went this direction instead of that direction because..." “I didn’t do this because...” "I did this because...’”

Many of our prepared questions will be answered without us uttering a single one! This approach also helps the employee understand that they are a crucial part of this process and we are here to learn from what happened, not to find fault. This method often uncovers underlying reasons for behavior, such as environmental factors or miscommunications. The presence of the supervisor during the site visit is equally important, as it allows the investigator to explore supervisory decisions and policies in practice.

Step 4: Root Cause Determination
The final step is determining the root cause, which may be singular or involve multiple contributing factors. It’s essential to dig deeper than simply attributing the issue to “operator error” or concluding that an employee “should be more careful.” The goal is to understand why the error occurred. Was there a lack of training? Were procedures unclear or not enforced? Was there a breakdown in communication between the employee and their supervisor?

Understanding these nuances allows the organization to address the underlying issues and prevent future incidents.
Root cause investigations are essential for preventing future losses. Following the four-step process helps organizations uncover the true reasons behind incidents. By fully understanding the why behind each incident, organizations can implement effective changes that promote risk reduction across the organization.