Apparent
Cause Analysis
(Near
Cause Analysis)
There
are well over 100 different investigation models in use with the
nuclear industry being one of the prime users of the Apparent
Cause Analysis model. It's also called Near Cause Analysis and
as the name suggests it's a method where determining the precise
root cause is not called for.
Here are a few of
many industry definitions of Apparent Cause Analysis:
- The
most probable cause for an event based on readily available
information.
- A
logical conclusion of cause based upon readily available facts
established during a limited investigation.
- A
cause derived with a minimum investigation of the condition
or event.
The
definitions suggest that a lesser investigation will be conducted
or is called for in order to address the apparent causes of an
incident. This is certainly in conflict with the almost sacred
approach of root cause analysis that most of us have used for
years. That is, anything less than a complete investigation means
we have stopped searching for answers too soon. As a result we
may end up fixing the wrong thing or simply addressing superficial
causes of the incident. Apparent Cause Analysis is just one of
the investigation methods used in the nuclear industry depending
on the significance of the issue.
Most organizations
have at the heart of their investigation program a causal analysis
process that uses a menu of check boxes or suggestions on three
distinct levels. These are:
- Immediate or Direct Cause,
- Basis or Indirect Cause, and the
- Root Causes.
Investigators,
especially at the supervisory level, usually have little trouble
in identifying the first two levels of causes, but are frequently
frustrated in trying to come up with the Root Cause their organization
will accept and then address. While they appreciate the need to
identify the Root Cause, they often feel it identifies too large
an issue and one that they have little control over.
If
we were using the Apparent Cause Analysis method we might identify
as a Basic Cause “ the lack or knowledge or skill ” as
being a causal factor. If we continued to drill down to the Root
Cause, we would probably be checking off “ Employee Training
.” Haven't we really said the same thing in two different
ways? If you address either of these two causes, you will have
fixed the problem.
I
see increasing numbers of organizations putting less emphasis
on identifying a Root Cause and more on focusing on the second
level of causes, the Basic or Indirect Cause; or they have merged
these two cause categories into a single one.
There
will always be incidents where a more detailed investigation is
called for, but for the majority of our investigations the idea
of doing Apparent Cause Analysis has merit. Organizations need
to have a written standard in place that dictates the depth each
investigation needs to go depending on the severity.
The
link below will take you to a TapRoot Newsletter on this topic.
TapRoot is a in depth root cause analysis process, and this article
presents one side of the argument on the Apparent Cause Analysis
process.
http://www.taproot.com/blog/SummitCurseApparentCause.pdf
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