Issue link: https://www.e-digitaleditions.com/i/1472963
July/August/September 2022 I 63 Suppose Joe showed up to work impaired and unable to perform his duties. Termination may be an action taken by the company, but it should not stop the launch of an investigation and corrective actions. More impor- tantly, perhaps Joe was impaired, and some or all of the other possible causes identified are also valid. For example, if it were found that Joe fell off the ladder because his uniform was faulty AND he did not have the knowledge to set up the ladder, then the one root cause would be that "Joe was not properly trained in ladder safety." The RCA outcome may revolve around how to better train supervisors to help employees, implement daily employee check-ins, or some other means to assure that history will not repeat itself. If the first reaction were to terminate Joe for his LTA and drop it there, then the company would lose the benefit of the learning opportunity availed during the fact-gathering stages. The company or organization would lose the benefit of stopping future accidents simply by not looking past the termination for the action. Perhaps this is a fault with the "Root Cause" nomen- clature which implicates a culprit or seems punitive instead of naming it something more positive. The reality remains that if done correctly, these activities can create a culture of positive change and improvement. Top-Down Support and Process Definition From the top down, there must be support for RCA initiatives. Often, there will be greater cooperation in completing RCAs when the process is viewed as leader- ship driven. This support includes mandating an atmo- sphere of no judgment and freedom of expression without stifling opinions. The latter part of the last sentence is the most significant. No one on the team should make anyone else feel excluded or belittle their comments. Stifling input is a sure road to failure, and this cannot be overly emphasized. There should be concise triggers for an RCA. These analyses take time and commitment. Launch actions should be well outlined with room to add or remove as needed. For instance, when cursory (i.e., quickly done with little detail) investigations show favorable outcomes, employee suggestions should receive special attention as a key RCA kick-off. Perhaps a company may decide FIGURE 3: Make certain the RCA team is truly diverse. that an RCA will always launch anytime life safety is involved or there is an LTA . Whatever the agreed launch point (e.g., more than 10-minute loss of systems, product quality returns), the commitment and support from upper management is key to the success of the process. Unfettered Inputs When garnering support for the RCA, inputs are one of the most critical steps. The entire project can be jeopar- dized if people are stifled from providing essential inputs. Considering both the 5 Whys and the Fish Diagram or whatever means chosen to drill down, inputs at all levels must be candid and forthcoming without repercussions. Rather than blaming a person, which happens too often, focus on the procedures and support that failed the person, not how the person failed the company. Sometimes actions happen in tandem. Build Diverse Teams People hear a lot about diversity and inclusion these days, but this process certainly highlights why this is impera- tive to problem solving. Everyone has different experi- ences, and they process those experiences differently. For example, someone with a degree will see things through the lens of the degree and its institution, whereas some- one with on-the-job training will see things through the lens in which they learned; certification candidates will have that lens. Someone self-taught will bring yet a different perspective, and someone with no knowledge can be valuable as a "new set of eyes" without any preconceived knowledge (Figure 3).