The problem with root cause analysis

Abstract

An 800 person forum comprised of Root Cause Analysis (RCA) practitioners from all over the world tried to define “Root Cause Analysis.” They could not agree on an answer. A smaller group was formed, composed in part by at least 5 major RCA consultants. They could not agree either. Several major Professional Societies have tried to define root cause analysis with the same results - disagreement! Each person, consultant, or organization will define “Root Cause Analysis” differently, because the depth pursued in an RCA is dependent on what the inquirer is willing to see. When a person only wants to understand the physical mechanisms of their problems, or to only see problems in their “Management Systems,” that is all they will see. RCA has become whatever people want it to be. This is the problem with Root Cause Analysis. It means dif- ferent things to different industries - even different things within the same industries. It is even difficult to find consistency within the same companies, or even sites within a company! It almost seems as if we’ve created an endeavor (called Root Cause Analysis) that does everything but look at “root cause!” We are the root cause of our problems - each of us and all of us. We always have been and we always will be. Our attitudes, beliefs, and assumptions about life cause us to behave in errant ways. Things that go wrong are the only phenomena that prompt us to reconsider these kinds of things. Unfortunately however, it seems that most Root Cause Analysis (RCA) methods encourage people to look at just about everything besides themselves. This paper will describe an effective, proven way to help peo- ple see themselves as part of their problems. It is opposite to the blaming and finger-pointing of the past, because instead of telling people their problems, this technique will describe how to help people discover their own role in things that go wrong. It is an introspective, evidence-based exercise that is life- changing to those who are willing to participate.