Root cause analysis is the process for determining the real cause of a problem, malfunction, error or oversight, so that the situation can be remedied and not occur again.
Root cause analysis practices can vary according to the category, for example safety, production, process, failure and systems.
However, all those categories are ultimately created operated and adapted by humans.
Root Cause Analysis Must Focus on the Human Element
Root cause analysis must ultimately be focussed on the human elements, because of our primary role in the creation operation and adaptation of everything we do.
Root cause analysis also useful in resolving all conflict, relationship breakdown, conscious and unconscious bias.
Root cause analysis can also be applied to what works, and what is better. For example, an appreciative inquiry beginning with “Why is this working so well?”
Whilst it is important to follow a rigorous investigative pathway to determine the facts and order of occurrences, our findings must result in the final root causes, which must be human, not mechanical or part of a process, product or system.
Neither must the root cause rest on the final finding of ‘operator error’ or ‘operator excellence’. That is an incomplete or false finding.
False Root Cause
An example of a false root cause is provided by the” five whys”, a Six Sigma tool – too often the fifth ‘why’ finishes at a broken process, or failure, or ‘operator error’ – and that is not enough. We still haven’t determined the root cause of the broken process, failure or operator error.
Example of a False Root Cause
John had been a truck driver for over twenty years without any incident.
Then one day, he ran off the road and his truck hit a tree. The truck was damaged, but reparable and John sustained mild concussion.
The safety investigation resulted in the determination of ‘driver fatigue’.
End of story.
Not so, we haven’t determined the root cause of the driver fatigue and why a fatigued driver drove.
If the investigator had asked why John was fatigued, and John was honest, John might say something like “I had a late night, binge watching Netflix” or some other truthful reason.
The investigator would then ask, “If you knew you were fatigued, why did you drive?”
John’s honest answer would be any or a combination of:
- “I thought I could handle it”
- “I didn’t realise I was so tired”
- “I didn’t want to tell anyone in case they thought I was incompetent”
- “I’ve driven in this state many times without an incident”
Now we know that there is an issue with John’s judgement and values, which can be improved. It probably also indicates the culture of the enterprise where John works, and that may need adjustment as well.
The Real Human Root Causes
Each of those answers reveal the only three possible human root causes of everything that can go wrong, including all conflict.
Those three root causes are:
- Fear
- Inappropriate habits (includes beliefs/values)
- Ignorance
The Remedies
The beauty of this awareness is that we now know the remedies:
- Courage – which comes from our values (usually sacrificed in the face of fear)
- Better practice – all habits, good and not so good are caused by practice
- Continuous learning – We can never stop learning, lest we succumb to the status quo and become irrelevant or useless.
These are also the causes of everything that can goes well. These are the causes of high performance.
The Revelation
Fear, Habits and Ignorance are the hallmarks of ego, a false identity.
Courage, Better Practice and Continual Learning are the hallmarks of our best true self.
If you agree with my thinking please share this – imagine the benefits this approach can bring to us all.
