The Impact of Language on RCA Investigations
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How many times have you read an incident report and have been left wondering what was being investigated, or what the causal relationships were all about? This often occurs when vague or nebulous descriptors are used to explain causal relationships. Below we give some examples of non-descriptive language commonly found in incidents reports and strategies you can use as a Root Cause Analysis facilitator to prevent ambiguity or misinterpretation.
Three types of vague descriptors commonly used to explain causal relationships, and how to address them:
1) “Poor”, “Inadequate”, “Ineffective” , “Insufficient”
Example: “poor maintenance”
Effects: Leads easily into the categorising of causes, such as “human error”, which can quickly move down the blame path. We will tend to end up with the same generic types of solutions for each category. These terms are often emotive, inflammatory, and can lead to conflict.
Solution: As a means of clarification, ask something to the effect of ...“what is it that makes the maintenance poor?” By challenging the imprecise words consistently you will create CLARITY where previously there was none.
2) “Time”, “Speed”, “Age”, “Weight”
Examples: ...it was “the shaft was worn” because of “wearing” over “time”
...“car crashed” because the person didn’t see the other car” and “speed”
...the pipe “corroded” because it was a “metal pipe” and “age”
...we couldn’t stop it because it was “rolling” and its “weight”
...Another example of a different context would be “maintenance”...i.e..the machine failed because of “maintenance”
Effects: Now whilst all of these causes probably have some specific relevance within the causal pathways in which you find them they all create confusion as there is no clear descriptor to explain the relationship. This will again lead to subjective assessments. People will interpret the reference in their own way. Speed will mean different things to different people, as will weight, age and time.
Solution: Typically what is required is to quantify each of these words. In other words: “How much time are you talking about?”, “What was the speed?”, “How old is it?”, “How heavy is it?” and “What is it about the maintenance that was less than adequate?”
3) “wrong”, or “incorrect”
Effects: This sort of description is purely subjective, opinionated and may not be based in fact. If what we are trying to do is to present the facts then these types of words would fail to achieve that.
Solution: Your task as a facilitator is to seek clarification of these words. Why is it wrong? What makes it wrong or incorrect? When these questions are asked the responses to them need to be recorded and added to the *Realitychart. The original reference has been replaced by something far more factual and meaningful.
Tip Provided by: Jack Jager, Apollo Facilitator and Trainer, ARMS Reliability
ARMS Reliability has been delivering Apollo Root Cause Analysis courses throughout the world for the last 16 years both at public seminars and at clients’ sites. Since 1988, 100,000 people worldwide have been trained in Apollo Root Cause Analysis. ARMS Reliability has trainers available to meet your training needs in North America, South America, Europe, Asia, Africa and Australia.
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* RealityCharting is a user friendly software solution created to help people better understand their problems and identify effective solutions that prevent recurrence.