The Baker Panel Report - ABSA

BP’s methods of root cause analysisBP considers root or system causes to be the “most basic causes that can reasonably be identified, that management has the control to fix, andfor which effective corrective actions for preventing recurrence can be generated.” BP recognizes that incidents typically have more than onecause. As BP notes in its incident investigation guidelines,It is very unusual for an incident to have one single cause. Normally incidents result from a chain or combination ofactions or errors, some going quite far back in time. This is why it is essential to have a systematic and thoroughinvestigation, following a consistent methodology, so that the chain of causes can be tracked right back to its origins. 61The Panel is concerned, however, that BP’s investigations may miss systemic causes by considering only causes in a direct, linear chain ofcausation as discussed above.BP utilizes several tools in conducting root cause analysis, including methods known as the Five Whys and the Comprehensive List of Causes.The Panel’s review, however, raises questions regarding the adequacy and thoroughness of BP investigations into incidents and near misses,especially as BP’s investigations relate to root cause analysis and the identification of multiple causes.As an initial matter, the Panel believes that BP’s exclusion of causes outside of management’s control in its definition of root cause 62 —if notcarefully applied—can result in inadequate consideration being given to systemic and management system causal factors. The Panelrecognizes that in creating the exclusion, BP intends to focus the root cause analysis process on failures that are correctable by management.However, if the exclusion is interpreted too broadly, such an interpretation may result in underlying management deficiencies not beingidentified. For example, the reference to “management” in this context should be read expansively to cover all levels of management. The rootcause analysis should exclude causes only if they are truly outside the control of BP—not just outside the control of refinery-level management.In the situation in which true root causes are not identified, proposed corrective action likely will address immediate or superficial causes, butnot the true root cause. In such cases, corrective action may be ineffective to prevent future incidents arising from the same root causes.> The “Five Whys”For minor incident root cause analysis, BP uses an approach called the “Five Whys.” Under this approach, the investigation team questions“why” the incident happened or “why” the unfavorable conditions existed. Specifically, the team selects an event associated with the incident,asks why this event occurred, and identifies multiple subevents or conditions that gave rise to the event. For each of these subevents orconditions, the team again asks why it occurred. The team records the subevents or conditions as an event tree. The team then repeats thisprocess five times to identify the root cause. One advantage of this approach is that it requires minimal effort and expense to traininvestigation team members.BP acknowledges several limitations to this approach, however, including that results are not “reproducible/consistent” and that systemcauses may not be identified. The “Five Whys” process can lead to a very narrow and superficial incident analysis and may not identify the bestcorrective actions—especially if the investigation team is not properly trained.Although BP documents discussing the use of this method state that it should only be used for minor incidents, it does not appear that BP hasconsistently defined what is minor. Sometimes seemingly minor events may be precursors for major accidents, and the identification andelimination of the causal factors of a seemingly minor event may prevent a major accident and therefore provide a valuable learningopportunity. For this reason, the Panel believes that it is important to ensure a thorough assessment of the root causes of even minor incidents.Performance Evaluation, Corrective Action, and Corporate Oversight C 198