AUDITING
TIPS
Root Cause
Analysis in EHS Audit
PAUL BEATLEY, ENHESA
DIRECTOR, PRESENTED AT
THE AUDITING ROUNDTABLE’S
INTERNATIONAL MEETING
ON OCTOBER 9 IN DUBLIN,
IRELAND ON THE TOPIC OF
PERFORMING ROOT CAUSE
ANALYSIS TO BETTER ASSESS
THE RISKS ASSOCIATED WITH
NON-COMPLIANCES UNCOVERED
DURING EHS AUDITS.
An array of methods and tools are available to
assess the underlying cause of noncompliance
findings uncovered in a typical audit, many of
which are included in the Enhesa Audit Protocol
ScoreCard and which help to pinpoint the root
cause of an instance, prioritize the corrective
measures required and better assess the potential
costs of addressing the root cause versus the effect.
Root Cause Analysis (RCA) is a method of problem
solving that tries to identify the root causes of
faults or problems. A root cause is a cause that
once removed from the problem fault sequence,
prevents the final undesirable event from recurring.
A causal factor is a factor that affects an event’s
outcome, but is not a root cause. Though
removing a causal factor can benefit an outcome,
it does not prevent its recurrence for certain. RCA
arose as a tool in risk assessment and problem
resolution in the 1950s as a formal study following
the introduction of Kepner-Tregoe Analysis in the
area of rocket design, development and launch in
the United States by NASA.
Fishbone
The fishbone is widely recognized as one of the
standard quality tools used in conducting RCAs.
Created by Kaoru Ishikawa (1915-1989) in Japan,
the fishbone cause-and-effect diagram is part of
every six-sigma program. It starts with just one,
single problem which doesn’t reflect the nature of real
world issues. It mixes causes and possible causes
without specifying evidence. And, it breaks apart the
fundamental cause-and-effect relationships within an
issue by grouping the causes into general categories.
It should be noted that the diagram starts with the
problem on the right and builds the causes to the
left because the Japanese language reads from
right to left.
The 5-Why Approach
The 5-Why approach is a basic approach to
cause-and-effect analysis. Every investigation,
regardless of size, begins with one Why question.
The “Why” questions then continue, passing
through five, until enough” Why” questions have
been asked (and answered) to sufficiently explain
the incident. The 5-Why approach, created by
Sakichi Toyoda (1867 - 1930), the founder of
Toyota, is a simple way to begin any investigation.
Cause Mapping
The Cause Mapping method actually uses
Ishikawa’s convention by asking “why” questions in
the direction we read. A Cause Map can start with
just 1-Why and then expand to accommodate as
many Why questions as necessary:
• Why did a particular non-compliance occur
• When the most logical response is tendered,
ask why that situation occurred
• And again asking why the circumstances were
such that the situation occurred
• etc, etc – to a level of five “whys”)
In the Cause Mapping method, a problem within
an organization is defined by the deviation from the
ideal state. A Cause Map always begins with this
deviation which is captured as the impact to the
organizations overall goals.
In addition to the standard “Why” questions, which
tend to create linear cause-and-effect relationships,
the Cause Mapping method also asks “What
was required to produce this effect?” Anything
that is required to produce an effect is a cause of
that effect. This question, “What was required?,”
builds a detailed Cause Map that provides a more
complete representation of the actual issue.
Causal Tree
In a causal tree, the worst thing that happened or
almost happened is placed at the top. In near-miss
situations, a recovery or prevention side is added
to capture how an error was prevented. In either
the near-miss scenario or the full-blown event
scenario, the next step is to provide the causes
for the top event, followed by the causes for those
secondary causes, and continuing on until the
endpoints are reached. These endpoints are the
root causes.
Decision Table
The RCA process can go one step further through
the use of a decision table to determine how
best to respond to the root causes that were
uncovered. The decision table considers the
severity levels of events: whether the event was
potentially life threatening or involved a serious
injury, had potential for minimal harm or temporary
injury, or had no realistic potential for harm. The
table also considers the probability of recurrence
and the detectability of the event. Suggested
X