Gordon Graham’s well-known saying, “That’s a problem lying in wait,” is repeated often for a reason. It is the responsibility of all public safety professionals to address problems lying in wait before they become tragedies. While every tragedy isn’t avoidable, many are—and those who see problems ahead of time must step up to address them. Lives, reputations and more can be saved through taking notice and taking charge early on.
Why are these problems lying in wait so common in public safety? Public safety by nature is a results-oriented profession—meaning we typically take an “all’s well that ends well” approach to incidents. But we cannot get by on luck. Even when tragedy is avoided, there must be disciplinary repercussions where proper procedure is circumvented. To avoid tragedy, we must make sure that solid policy and procedure are readily available and enforced in our agencies, and personnel must be equipped to adhere to proper policy and procedure.
Why vs. What
When tragedies occur, we are often quick to assign blame to the “proximate cause”—the thing immediately preceding the tragedy. This is easy to do and requires less time and critical examination than a deeper analysis. The proximate cause deals primarily in the “what”: What happened? We often arrive at the conclusion that the involved personnel made a “bad decision.” It can become easy to write a tragedy off as a one-time exception, when, in reality, the circumstances or issues at play in the tragedy may be regular occurrences that simply had not yet resulted in a tragedy.
In public safety, we need to be equally as concerned with the “why” behind the situation: Why did this happen? Why did the officer make that decision? This is simply what root cause analysis is: Asking why and continuing to ask why. As you continue to dig deeper, asking why, why, why, you have the opportunity to find patterns—patterns of behavior in personnel and supervisors, patterns of poor policy and procedure, patterns of incomplete or inaccurate post-incident analysis, and more. And maybe you—or someone else—knew about these patterns before but did nothing about them. It’s better to feel the growing pains and make the necessary changes before tragedy strikes than to do nothing and see loss of life and other tragedy take place in your agency and community.
How can you use root cause analysis to stop tragedy in its tracks?
Root Cause Analysis: Why Not?
If root cause analysis, both before and after tragedies, is so important, then why do agencies not take part, choosing instead to assign the blame to a proximate cause and move on? For one thing, it’s easier. Because root cause analysis may reveal underlying issues within an agency, the blame may not be so clear cut. The dangerous phrase “We’ve always done it that way” may also come into play here. When agencies conduct root cause analysis, it opens up the potential for change, which then creates the opportunity for resistance to change.
And what will you, leader or supervisor, do if the blame falls in part on you? Whether from laziness, fear of self-implication through conducting root cause analysis, or a results-oriented mindset, choosing not to conduct root cause analysis within your agency will only leave the opening for more tragedy in the future.
The Five Pillars
Root cause analysis will virtually always reveal an issue within one of the five pillars of organizational risk management: people, policy, training, discipline and supervision. Whether it’s a problem with recruitment and hiring practices, policy and procedure development and implementation, training content and frequency, supervisors not taking action, or lack of discipline, understanding these five pillars makes root cause analysis more effective and helps agency leaders know how to address the problems identified.
Problems lying in wait are just that. It is not a question of if, but when. Take time to think through what everyone at your agency may know, but no one does anything about. Beyond looking at your own agency, also consider what you can learn from other agencies. How can you analyze events at other agencies to prevent tragedies from taking place in your own? How can you use root cause analysis to stop tragedy in its tracks?
Watch the webinar, “A Deeper Understanding: Root Cause Analysis in Law Enforcement,” with Gordon Graham and Chief (Ret.) Mike Ranalli for further discussion on and examples of root cause analysis.