I was called to help this company to investigate the root cause of all the non-compliance observations they got on a recent third-party audit. It turns out that a couple of those observations were recurrent, and the audit agency wanted to see a corrective action preventive action (CAPA) report for each. The experience was the perfect opportunity to have department and line leaders learning and practicing how to do root cause analysis.
Soon enough, after we start analyzing the first observation, the group concludes that the root cause was human error. The corrective action to avoid recurrence was retraining. I moved on to the next two, obtaining similar results. I know three points are not enough to say there is a pattern, but in this case, it was enough to prove my point.
It is common to choose employee retraining as a corrective action, but because human error is not the real root cause, it will not prevent the problem from happening again. RCA requires persistence to keep asking why until finding the end cause. If you stop digging before finding the underlying cause, the process fails. You end up working with a symptom or a proximate cause. In the example above, human error is the symptom or physical source. The source of it is the real root of the problem.
Asking why the person made the mistake will help to identify the real root cause. Keep asking why to dig deeper into the problem. Human error is often the product of inadequate processes, lack of resources, using the wrong tools, complicated work instructions, too many interruptions, or noisy environment, between others.
Do you want to find the real reason for human error? Engage the team, the people who create value, those who actually do the work, and ask why. I bet you that they will have lots of ideas to improve the process and minimize or eliminate recurrence. Humans are not perfect, acknowledge that fact and design robust systems that minimize defects or errors. Visual management and mistake-proofing devices are good tools to accomplish that.
Next time you find that the cause of the problem is human error, keep digging! Why humans erred? Be as curious as a cat, find the real underlying cause and improve your process.
