Monday Accident & Lessons Learned: What do you think of this Root Cause Analysis…
On November 6, I wrote about a “Safety Pause” at Savannah River Nuclear Solutions.
The last paragraph of the article was:
“Let’s hope that the root cause analysis of the incident will explore the management system related failures that led to the reasons for the degraded emphasis on nuclear safety and security that caused the ‘Pause’ to be needed and not be an example of the blame game that points the finger at workers and low level supervisors and their actions.“
So here is what the Aiken Standard wrote about the SRNS root cause analysis:
“Following a root cause analysis of the incident, Spears said the incident was a result of the work team’s willful procedure violation and its unwillingness to call a time out. As a result, the contractor addressed the job performance of individuals using the SRNS Constructive Discipline Program and took appropriate disciplinary actions, according to SRNS.”
What do you think? Did they look into Management System causes?
If they don’t find and fix the Management System causes … how will they prevent a future repeat of this incident?
In my experience, very seldom is someone a “bad person” that needs to be corrected using a discipline system. Usually, when someone breaks the rules, it is because a culture of rule breaking (or expediency) has taken hold in order to deal with unrealistic goals or unworkable procedures.
I don’t think I have ever seen a team of bad people. If a “team” has gone bad (especially if a supervisor is involved), I would bet that the culture of expediency has been promoted. This bunch was just unfortunate enough to get caught in a serious incident and were handy to blame. No reason to look for any Management System causes.
This is how a culture of expediency exists alongside a culture of blame.
What can you learn from this incident?
One reason you use the TapRooT® System for root cause analysis is to find Management System root causes and fix them so that your management and employees don’t slip into a culture of expediency and blame.
