Water companies invest considerable time and expertise investigating pollution events, asset failures, operational disruptions, safety incidents and customer complaints. Yet remarkably similar problems continue to occur. The question is not simply whether we are investigating these events well, but whether we are learning enough from them collectively.
A good Root Cause Analysis should explain why an event occurred, identify the factors that contributed to it and lead to actions that reduce recurrence. But even a good investigation has limitations when treated as an isolated piece of work.
An event happens at one site, an investigation is completed and actions implemented. Six months later, something similar happens elsewhere. Unless findings can be connected, the organisation risks learning the same lesson twice.
The problem may be bigger than the event
Most significant events have multiple interacting causes. An investigation might identify issues around competency, procedures, maintenance, communication, equipment, workload or management decisions. Together, those causes create a distinctive fingerprint of why that event occurred.
The real opportunity comes when we start comparing those Event Fingerprints.
If competency appears repeatedly across 20 investigations that becomes much more interesting. Perhaps one region has a concentration of procedural causes while another experiences recurring equipment issues.
Individual investigations cannot reveal these patterns; collectively, they can.
A single RCA explains an event. Multiple RCAs begin to explain an organisation.
Turning investigations into organisational learning
Achieving this requires consistency. It does not mean forcing every investigation through the same RCA method, but there needs to be enough common structure and language for findings to be meaningfully compared.
Investigation activity also needs to be coordinated rather than distributed across disconnected reports, spreadsheets and local systems.
When Event Fingerprints, causes and actions are captured consistently, shared themes become visible. We can identify causes that repeatedly appear across unrelated events and understand whether previous interventions have changed the pattern. Learning discovered by one team can then be made available to another.
“One of the biggest frustrations we hear from investigation professionals is seeing the same problems come back again and again. Often, it isn’t because the original investigation was poor. Good people have done good work, identified causes and taken action. The frustration is that the learning has stayed with that investigation, team or department. If we connect that knowledge across an organisation, every investigation has the potential to make the next one better.” Ed Wells, Chief Strategy Officer, What Caused This
This is where RCA begins to move beyond event investigation and towards organisational intelligence.
The water industry already generates enormous knowledge through investigation. The challenge is ensuring every new RCA adds to what the organisation already knows.
The greater opportunity is to use what we learn from one event to prevent similar problems occurring across the organisation.
Author
Ed Wells is Chief Strategy Officer at What Caused This, a company developing digital Root Cause Analysis platforms used by organisations investigating complex operational and environmental incidents.
More information: whatcausedthis.com
