Blown Opportunities: Lessons Learned from Flammable Gas Releases

An incident has occurred at your facility. What does your team do now to figure out what, why, and how it happened so that you can prevent this or a variant from occurring again? Incident investigation and root cause analysis (RCA) are two key activities that facilities can use to accomplish these objectives. These two analytical concepts are often used interchangeably and consequently incorrectly. These aren’t the same thing, and misapplication of the activities can pose the hazard of misunderstanding the direct causes of the incident, misapplying resources to ineffective corrective actions, and even lead to a higher likelihood of recurrence. These are most often sequential activities with overlap and may involve different teams or team structure.

Identifying the direct cause and contributing factors is the first and most critical step to analyzing deeper questions of causation. Then, understanding the root cause(s) of an incident or near miss may allow the facility to prevent recurrence or the occurrence of other, related events. However, the quality of the RCA is directly related to the quality of the incident investigation. The RCA necessitates that the distinct elements of the incident and the direct cause(s) are known and understood.

In practice, various internal and external priorities may shift the focus to implementation of corrective actions before all pertinent facts have been collected and analyzed. An incomplete data gathering effort can result in the loss or omission of critical information, and the misallocation of resources to implement corrective actions based upon flawed conclusions. Perhaps most importantly, the belief that a direct cause has been properly identified, and its root causes eliminated, may lead to a false sense of resilience despite the persistence of an unidentified hazard.

This presentation examines the differences between these approaches based on the analytical methods, applies case studies of the authors’ collective experience, and asks the question: when can you confidently transition from incident investigation to root cause analysis?