Fuel and Friction

The elements of success and failure in root cause analysis

February 05, 2024 Photo

We in the risk management world are an insular group. Armed with our statistics and our pictures of disastrous outcomes, we are convinced that our presentations and forms are brilliant—while we quietly rationalize the consistently low results. 

A charter school system where I consulted had significantly disparate flu-related absences by teachers and administrators between their schools, even though the flu-related absenteeism rate amongst the children was statistically comparable. Everyone from the risk manager to the human resources director to the superintendent was left without explanation. We will come back to this in a moment. 

A particularly bad foot crush accident at a manufacturing facility resulted in a partial foot amputation. The root cause analysis (RCA) process determined that the root cause was “failure to follow procedure, process, or protocols.” The resulting safety meeting was attended by the bulk of the employee’s coworkers. Although all were moved by the tragedy, a number of the coworkers were observed with improper footwear. The company predictably announced its punitive approach to future violations of the footwear protocol. A month later the footwear issue continued unabated.  


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Why did the threat of punishment, promise of reward (gift cards to a coffee shop or chain restaurant), and the shock of a tragedy to a coworker not inspire compliance? Even after the company negotiated an agreement with the union allowing employees to submit the purchase receipt and have the company reimburse the employee, the results were less than total.  

The answer to the improving the footwear compliance lay in the lessons learned from flu absences at the school district mentioned above. The issue at the school was not one of anti-vaccination. A survey of the schools revealed that there was a near identical percentage of people opposed to vaccines in general, so attitude was not the differentiator. Still, one school had over 80% vaccine compliance while the other school had about 50% compliance. While there were a couple of factors that might have influenced the different compliance levels, such as age of the employees, the most unique factor was that the higher performing school partnered with a health care provider to provide flu shots in school while the other school did not arrange the convenience. Both encouraged flu vaccination, but one removed the element of “friction.” 

Many risk managers perform RCA activities for their internal or external clients with the skill of an amateur magician at a five-year-old’s birthday party. They quickly get to the point of determining that the root cause was “lack of sufficient protocol, procedure, or process” and/or “failure to follow protocol, procedure, or process.” And then, with the same skill as pulling a quarter out of the birthday child’s ear, they announce that the corrective action is to “strengthen the protocol, procedure, or process,” and/or “punish the offender—put a note in the personnel file and send the worker home without pay for the first offense and terminate the employee for the second offense.” Finally, the risk manager completes the act with pulling the paper flowers out of his sleeve by adding, “and hold the supervisor accountable for failing to supervise.”  These actions are called “fuel.” 

Most programs rely on adding more fuel such as procedures, incentives, and penalties. What these risk managers fail to consider is removing the friction. Think of it like a bullet. The fuel is the gunpowder that causes the bullet to fly out of the gun barrel. The bullet will eventually fall to the ground because of gravity and the air friction. Add more gunpowder and you add more air friction. The answer: Make the projectile more aerodynamic, thereby reducing the friction. It’s the same for corrective actions.  

The company where the foot injury occurred had a safety committee that appropriately had more front-line workers than managers. As we started to discuss the accident and the RCA, it was noticed that someone on the safety committee had noncompliant shoes. Rather than becoming the footwear police, we questioned his mindset. What we learned was that he knew the risk, and he knew he could get the cost of the safety shoes reimbursed, but he still did not comply. He explained that his children were the most important thing in his life. When he leaves the jobsite, it is critical that he has quality time with his children. By the time they are in bed, the stores are closed. He also explained that many of his coworkers do not have the money to lay out for the shoes and then wait for reimbursement. These were the friction points. The corrective action that was needed was to arrange to have a shoe vendor come out with a van and give the workers a chance to shop the shoes onsite. Thereafter, the company got a discount for the large purchase and paid for the shoes. Compliance approached 100%.  

Shortly before attending a safety visit at a construction site, a company had a ladder accident. The company did its standard RCA concluding “failure to follow protocols” by the employee and by the supervisor. The safety team that performed the RCA began by checking to see if they had a schedule for ladder training. They did. Did they follow the schedule? They did. Did the employee attend the training and sign the form that stated that he attended and understood the training? Yes. Well, then the RCA was a success in revealing the root cause? No. The training consisted of the line manager presenting the material and demonstrating the activity. Everyone signed off that they understood the training. 

However, the workforce spoke four different native languages. The friction in the process was that the attendees may not have understood and did not want to stand out, or they thought they understood but missed the critical element necessary for true understanding. The company was more focused on the fuel provided by process than the friction created by the group dynamic of peer pressure. Having each attendee demonstrate understanding would have reduced the friction. 

Please do not misunderstand what I am saying: I am a big proponent for RCA and have spent many long hours teaching it. But RCAs have two inherent shortcomings: going down the wrong path by assuming your understanding of things or by lazy analysis; and having preconceived notions of corrective actions. Like the flu in the school that did not make vaccinations easy, these shortcomings spread like a virus. 

I witnessed a risk manager excoriate his external client for failing to file a claim within 24 hours. “Did you write her up?” was all he wanted to know. The client explained the extenuating circumstance that led to the failure, but it did not matter to the risk manager: “If you don’t write her up, she will never take it seriously. This has to be as serious as the most important function of your company.” I interrupted by pointing out that the extenuating circumstances could occur again. Perhaps the answer was to have a backup person to perform the function when necessary. If the goal is timely reporting, having a backup person removes the friction for the activity.  

So, what is the solution? It starts with realizing that the corrective actions, like work shoes, cannot be one size fits all. The friction will cause a blister to your feet and your program. Focus on the friction, not the fuel.  

About The Authors
Jeff Marshall

Jeff Marshall is a risk management and claims management consultant.  imanagerisk4u@gmail.com

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