Issue link: https://www.e-digitaleditions.com/i/1472963
62 I ICT TODAY FACTORS FOR SUCCESS Brainstorming and Devil's Advocacy Brainstorming is one of the most critical steps in RCA and, if done correctly, can be tremendously valuable. For this entire effort to be most effective, a space devoid of judgment must be provided to assure that all involved feel free to express their thoughts and ideas without impunity. In fact, this is one area where diversity and inclusion have a massive bearing on the success of the outcomes. Bringing multiple experiences, methodologies, and insights to one problem creates the necessary environment for real brainstorming. Sometimes the ones who know the least about the problem can ask the right questions to highlight things others intuitively know. For instance, someone that has been in a job a long time may know to hit enter when errors fly. Historically, that could have been the right solution. But should another person take over those responsibilities, he or she may not know to hit enter. Perhaps at this point "just hit enter" was the wrong thing to do. These innocent questions highlight the truth behind the statement that there are no silly questions except the ones unasked. Actions Versus RCAs Corrective actions with personnel should not be a part of the RCA process. If someone does something that warrants disciplinary action, that action needs to be separate from any RCA. For instance, if someone shows up on-site intoxicated, the corrective action could be to make them leave, get counseling, or fire them on the spot as dictated by company policy. An actionable offense should be dealt with as outlined in company policy, but it is not that simple. If an RCA were to occur, it would involve any incident that occurred. For example, the actions of the person and how his or her actions can be avoided. Suppose Joe fell off a ladder and hurt himself on the job, creating a lost time accident (LTA). If company policy states to launch an RCA anytime there is an LTA, the RCA will investigate why it happened and how to stop it from happening in the future because employee turnover is expensive. Any disciplinary actions need to be separated from the need to improve overall safety while satisfying employees and showing support for their participation and growth. RCAs should not be used as a disciplinary action tool. Instead, they should improve overall business processes and outcomes. The RCA may investigate the accident and deter- mine that Joe did not have his ladder in the proper position. A knee-jerk reaction might be to discipline Joe for not putting his ladder up correctly. But drilling down, the team realizes that Joe was not equipped with the right ladder or did not have the knowledge that he needed to set up his assigned ladder correctly. Perhaps the team ascertains that the company assigned uniform Joe was wearing had a flaw that caused him to get caught on the ladder. Another outcome could be that the ladders are faulty, and other employees had similar problems. Maybe the area where he had the accident does not allow for safe ladder use, and supplemental harnessing would have helped. All of these possibilities come to light through the RCA process. One issue keeping some RCA exercises from succeeding is that people are not comfortable and undoubtedly not forthcoming with information if they think there is the possibility of punitive action. There- fore, RCAs should not be used as a disciplinary action tool. Instead, they should improve overall business processes and outcomes. When life safety is involved, those incidents need to be addressed differently. Negligence and dereliction should not receive the same treatment as lack of knowl- edge. Therefore, an RCA would not apply to this case if it is actionable elsewhere. However, an RCA could be launched in an investigative manner to improve overall safety at the workplace.