One-Off or Systemic: The Search for Root Causes

by Julius DeSilva

Accidents and failures, whether in maritime, aviation, healthcare, or nuclear settings, are often subjected to intense scrutiny to determine their root causes. However, the challenge lies in distinguishing whether an event is an anomaly or a symptom of a deeper systemic issue. This analysis is crucial as it directly influences the actions taken to prevent a recurrence or occurrence elsewhere. A management system approach, such as those outlined in ISO 45001 for occupational health and safety, ISO 9001 for quality management, or ISO 14001 for environmental management, provides a structured framework for systematically and proactively addressing risks when data exists.

Analysis of root causes: systemic failures

Root cause analysis is a fundamental investigative tool used to trace an incident to its origins. However, many organizations focus on immediate, apparent causes rather than examining systemic contributors and true root causes. Systemic failures result from weaknesses in policies, processes, or culture, and therefore, often recur in different forms over time.

The management system approach advocated by ISO standards and other industry-specific standards like the ISM code emphasize continual improvement and risk-based thinking. The intent of these standards is to reduce the probability of systemic failures by integrating safety, quality, efficiency, security, and environmental management into everyday operations.

Systemic failure example: Chernobyl

I recently read the book Midnight in Chernobyl, which outlined the 1986 Chernobyl nuclear disaster and the underlying systemic failures that contributed to this incident. Unlike isolated accidents, Chernobyl resulted from a combination of design flaws, operational errors, and a deficient safety culture. Key systemic issues included:

  • Design flaws. The RBMK reactor used in Chernobyl had an inherent positive void coefficient, meaning an increase in steam production could accelerate the reaction uncontrollably.
  • Operational failures. A safety test was conducted under unsafe conditions, including a reduced power level and disengaged emergency shutdown mechanisms.
  • Cultural and regulatory gaps. A lack of safety culture, insufficient training (and thus competency), and an authoritarian management style amounting to complacency discouraged questioning of unsafe practices.

These root causes culminated in an explosion that released massive amounts of radioactive material. European countries are so tightly packed that winds freely spread the outfall without borders. The systemic nature of the disaster was later addressed through international nuclear safety reforms, including the establishment of the International Atomic Energy Agency’s safety standards and stricter ISO frameworks such as ISO 19443, which outlines quality management system requirements for organizations working within the nuclear sector.

Other systemic failures

Deepwater Horizon oil spill (2010)

Another example of a systemic failure is the Deepwater Horizon oil spill. This incident was not merely the result of a single mistake but a consequence of systemic lapses in safety practices, regulatory oversight, and risk management. Contributing factors included:

  • Cultural deficiencies. The organization prioritized cost cutting over risk mitigation
  • Inadequate risk assessments. There was poor well-integrity testing and misinterpretation of pressure data.
  • Regulatory weaknesses. There was insufficient government oversight and a lack of stringent industrywide safety protocols.

This catastrophe led to significant regulatory changes, including the implementation of stricter safety and environmental policies within the oil and gas industry, aligned with ISO 45001 and ISO 14001.

The Boeing 737 MAX crashes (2018, 2019)

The Boeing 737 MAX crashes further illustrate systemic failure. Investigations revealed that flaws in the aircraft’s Maneuvering Characteristics Augmentation System (MCAS) were not adequately addressed due to:

  • Design and engineering oversights. Critical safety features were made optional rather than standard.
  • Regulatory gaps. The FAA relied excessively on Boeing’s self-certification.
  • Organizational pressures. The corporate culture emphasized speed-to-market delivery over comprehensive safety testing.

This resulted in significant regulatory reforms, including tighter oversight and compliance with international aviation safety standards.

Fixes vs. systemic longer-term improvement

Addressing failures can be approached through quick fixes or long-term systemic improvements. Each approach has its advantages and disadvantages:

Quick fixes

Pros:

  • Immediate resolution of pressing issues
  • Cost-effective in the short term
  • Prevents further damage or loss

Cons:

  • Does not address underlying systemic issues
  • Can lead to recurring problems if not supplemented with deeper analysis
  • Often reactive rather than proactive

Systemic longer-term improvements

Pros:

  • Addresses root causes, reducing the likelihood of recurrence
  • Enhances organizational resilience and safety culture
  • Aligns with ISO management systems, ensuring continuous improvement

Cons:

  • Requires significant time and resources
  • May face resistance from stakeholders due to cultural inertia
  • Implementation complexity can slow down immediate corrective actions

A balanced approach is often necessary—implementing short-term fixes to mitigate immediate risks while developing long-term systemic improvements to ensure sustainable safety and risk management practices.

What if we cannot foresee all risks?

Even with rigorous management systems and risk assessments, not all risks can be predicted. Organizations must be prepared to address unforeseen risks through:

  • Resilient systems. It is important to develop adaptable and robust safety management frameworks that can respond effectively to new threats.
  • Proactive learning. The organization can encourage a culture of continuous learning and scenario planning to anticipate emerging risks.
  • Redundancies and safeguards. Implementing fail-fail safe redundancies and contingency plans can mitigate the effects of unforeseen events.
  • Stakeholder collaboration. Engaging industry experts, regulators, and other stakeholders to share knowledge can help improve collective risk awareness.

Despite the lessons from Chernobyl, 25 years later the Fukushima disaster occurred. An earthquake of this magnitude was not foreseen as a risk even though in 1896 (as highlighted by an engineer on the project) an earthquake of magnitude 8.5 hit near the coast where the reactor was to be built. After Chernobyl, the 1970s-built reactor in Fukushima was not upgraded with the latest safety features due to high costs. Japan’s nuclear industry had a history of regulatory complacency and reluctance to accept international recommendations

ISO 31000, which addresses risk management, emphasizes the importance of resilience and adaptability in the face of unpredictable risks. By fostering a commitment to learning and preparedness across the organization, businesses can better navigate uncertainties while maintaining operational safety and efficiency.

The benefits of a management system approach

A management system approach, as defined by ISO standards, provides the following advantages:

  • Structured risk management. ISO 31000 ensures systematic identification, assessment, and mitigation of risks.
  • Continuous improvement. The Plan-Do-Check-Act (PDCA) cycle described in ISO 9001, ISO 45001, and ISO 14001 encourages learning from incidents to prevent recurrence.
  • Organizational culture change. Implementing ISO standards fosters a risk-oriented mindset, reducing the likelihood of systemic failures.

ISO management systems, when implemented and sustained, can act as a preventive tool to proactively manage risk.

Conclusion

Understanding whether an accident is an anomaly or a systemic failure is critical in determining the appropriate response. Sadly, at times industry must incur the cost of the nonconformity to learn the lesson. Organizational “can-do” attitudes lead to risk normalizations where dangerous conditions are seen as normal. Further, organizational and demographic cultures do not encourage challenging authority or questioning of decisions. Absence of accidents, incident reports, and near misses give a false sense of complacency that things are working well. This may lead to over-confidence in decision making, lapses in regulatory oversight, and deferring of resource allocation to other “priorities.”

Systemic failures indicate deeper vulnerabilities requiring long-term corrective actions. The application of ISO management systems offers a proactive and structured approach to accident prevention, ensuring that organizations move beyond reactive responses to fostering a culture of continuous improvement and risk management. By embracing these principles, industries can mitigate systemic risks, ensuring safer and more resilient operations.

Note – The above article was recently featured in Exemplar Global’s publication ‘The Auditor’. Click here to read.

Stop the Firefighting: Use Effective Root Cause Analysis

Root Cause Analysis (RCA) or Causal Analysis when applied correctly should help to prevent the recurrence and occurrence of similar issues within the organization. Why then is such little time, money and or effort afforded to it?

Heroes save the day! Yet again! How often have we come across news articles that laud those who manage the crisis, stop the plane from crashing or save the patient. The reality in any casualty is that, a system failure has resulted in a non-conforming product/service, including failed inspection. Organizations should laud and appreciate those who prevent incidents/ accidents/non-conformities and those who perform effective root cause analysis. Those who recognize near misses and perform CA  should receive equivalent if not more praise.

The root cause of many diseases is lack of a healthy lifestyle. Presumably, annual medical check-ups would show the flaws and enable risk appreciation to prevent a disease or illness from manifesting itself. This data however may not be enough to provide an accurate diagnosis or prevent a serious medical condition. Perhaps some may see the regular check-ups as a waste of money and time! This may help to explain why companies are reluctant to do root cause analysis when non-conformities arise. Their instincts are to do the firefighting when something goes wrong. This basic firefighting often appears to be less expensive, quick and seemingly more convenient. However, as has been proved again and again in various fields (quality, safety, security, etc.) prevention is better and more cost effective than the cure.

Why Problems Persist?

There are many methodologies for root cause analysis (RCA). It is not the intent of this article to educate its readers on the various RCA methodologies. Before we delve into why problem persists let us considers why problems occur. Problems usually occur because of the lack of a functional well implemented management system. This includes the lack of management commitment, timely identification of risks and lack of controls/adequate resources for the processes. Despite repeated warnings from their doctor, patients choose to continue living their current lifestyle. During incident investigation interviews this comment is often heard ‘this is the way we always did it’. Humans are not always accepting of changes and ‘if it ain’t broke then why fix it?’ Management of change is never easy. The larger the organization the more difficult it is to enable the change. Often in management systems, problems are ‘fixed’. This makes the issue go away albeit temporarily. Everyone likes a good score card and ‘fixing’ the issue makes everything look good again. However, when the root cause(s) are not addressed this dragon will raise its ugly head again.

When root cause analysis points toward leadership or top management, the job security aspects may prevent the middle managers from completing the RCA process. This political limitation, to avoid exposing process issues within the ranks of leadership are counterproductive, and yet a reality. As preposterous as it may sound, in some cases leadership may opt for paying the fine when things go wrong and then proceeding as is. This is seen as the ‘less expensive’ option than resourcing actions to prevent the recurrence/occurrence of problems. Conflicts of interest in the workplace, can often be a reason for a lack of effective root cause analysis.

Stopping the Firefighting.

With all due respect to firefighters and other emergency personnel, organizations want to solve the problem, so they do not have to call them back! This means getting to the root cause(s) of the incident. Very often when identifying the root cause(s), the work group or practitioners often stop short of finding the actual “root cause.” These may be the immediate direct or indirect causes. The root case may lie in another part of the organization and often gets missed. Root Cause Analysis when done correctly drives systemic changes to prevent similar issues from cropping up again. As with everything else the RCA team needs the backing of the leadership including the needed resources to be effective.

In conducting effective root cause analysis, the inputs of customers and other stakeholders may be needed. For effective root cause analysis is of interest to all organizations that are integral to the successful implementation of a management system. The element of social responsibility in the defined duties of leadership need to be audited and have consequences when customer focus is lost. The new root cause analysis model should have an element of responsibility attributable to the top management. The intent, not to encourage a blame culture, but a responsibility culture. As a part of QMII’s management system implementation we train selected candidates as a problem-solving team to enable and empower continued success of the system. To sit in the fire house and focus on other initiatives such as innovation, social responsibility etc. an organization has to proactive rather than be responsive.

Conclusion

Leadership often questions why money spent on management systems, particularly when based on ISO Standards do not work? Why a conforming product or service is not constantly delivered by an organization? Mature organizations recognize that the only bad nonconformity (NC) is the one that they do not know about. Once the NC is identified, the system must drive Correction and CA (corrective action, based on RCA). Closed NCs added to the database, along with the proper analysis of the information, will allow system users to appreciate risks and trends to identify the opportunities for improvement (OFI). However, all this will fail if the MS (management system) users do not understand the value of RCA.

For the success of a Management System, its outputs based on inputs must deliver conforming products and services.  When the Management System does not achieve this, all stakeholders should be interested in the root cause analysis and corrective action.