Insight from hindsight: A practitioner’s perspective on a causal approach to performance improvement

The petrochemical industry works relentlessly on many fronts to improve performance and to create desired performance outcomes. Companies’ approaches vary widely; yet despite best efforts, the industry continues to experience periods of undesirable performance outcomes in product quality, reliability, process safety, environmental, and personal injury. The industry continues to search for better methods, techniques, and technology that are assumed to be missing, but the causes of incidents illustrate that what is in the way of improving performance may not be what is missing but rather what already exists.This paper provides an alternative perspective of performance problems viewed from underlying causes and patterns of causes of incidents in these so-called “high hazard industries” (Carroll, 2004) across several years and geographic regions. The perspective includes two distinct insights.First, although problems can have a wide range of outcomes and impact, the underlying causal patterns are relatively few in number. These few represent essential elements that are repeatedly discovered in various forms under many unrelated problems.Second, several common obstacles within organizations often inhibit the ability to find the causes, learn from the causes and to effectively address the causes of performance problems.The conclusion is that when these repeating patterns are combined with a limited ability to effectively find, learn, and eliminate the causes, organizations are left with repeating periods of performance problems despite well-intended efforts to improve.