Problem with Root Cause Analysis
In a nutshell, the problem with root cause analysis is in the
question "what is a root
cause?" When an
800 person forum comprised of Root Cause Analysis experts from all over the world
tried to answer this question, they could not agree on an
answer. A smaller group was formed, composed of about 10 major
Root Cause Analysis consulting groups. They could not agree either.
Several major Professional Societies have tried to agree, with the
same results -- nothing!
Think about it.
The causes of something that happened "today" occurred "yesterday."
The causes of "yesterday's" problems occurred "the day before that."
In the limit, the causes of the causes can
literally be traced back to the
beginning of time.
no-one really wants to trace any of our problems all the way back to
the beginning of time, each
person, consultant, or organization defines "root cause"
PROBLEM with Root Cause Analysis
is that it has become whatever people want it to be.
If you ONLY want to see problems in your "Management Systems,"
that's all you will see. If you ONLY want to understand the
PHYSICAL mechanisms of your problems, that is all you will see.
These days, Root Cause Analysis has become one of the CAUSES of our problems
because many have tricked themselves into thinking they're actually
addressing ROOT CAUSES when they're not even close, and then
they wonder why new problems continue to
Latent Cause Analysis™
Latent Cause Analysis is a trademarked phrase coined by Failsafe to
distinguish it from other root cause analysis methods.
It addresses "root cause" in the most effective of ways; by focusing
on human accountability by requiring
people to see themselves as part of their problems to such an
extent their behavior will change in the future.
Latent Cause Analysis is Failsafe's brand
of Root Cause Analysis.
Latent Cause Analysis requires the
right people to answer the
following questions, after having reviewed the evidence:
What were the
Physics (or mechanics) of the Incident?
Who enabled the
physics? How did they do this?
What is it about the
way we are that influenced these people and what are we
going to do about it?
Latent Cause Analysis has been life-changing to
many who have taken the journey.
Root Cause Analysis
and Latent Cause Analysis from Failsafe Network
Who is Failsafe
My name is Bob Nelms, and I am founder of Failsafe Network, Inc. It is
my hope to help you (and myself as well) learn from things that go
wrong. Things that go
wrong in our lives have the unique ability of being able to teach us
things that nothing else can teach.
Unfortunately, most Root Cause Analysis methods stop FAR short of
where they ought to be focusing. It seems that most Root Cause Analysis
(RCA) methods encourage people to look at anything and everything
you explore varying Root Cause Analysis methods and approaches, note
what each of these methods are trying to help you see. Most methods will help you compare
your problems with a pre-defined "perfect world."
Lists of "possible causes" are evidence of these types of methods. Was
it a "procedural flaw?" Maybe you didn't have sufficient "barriers" in
place. Or perhaps "inadequate training" was the "root cause."
these kinds of approaches have brought us a long way from where we were,
they are also tending to wind us into a tighter and tighter ball
from which it will be almost impossible to SEE the following truth:
WE are the
root causes of our problems -- each of us!
Any Root Cause Analysis approach that does not
help people LOOK AT THEMSELVES IN A MIRROR
is, in itself, a significant cause of our problems.
read-on about Failsafe's brand of doing Root Cause Analysis, called
LATENT CAUSE ANALYSIS™. We think you'll like it.
From the Blue-Ridge Mountains in
Virginia, but active world-wide: United States, Canada,
England, Ireland, Netherlands, Spain, Venezuela, Thailand, Indonesia,
Root Cause Analysis is
If Root Cause Analysis (or RCA) at your site is ONLY
something performed by an elite group of specialists on major
problems using sophisticated investigative methods, something is
Your Root Cause Analysis efforts ought to be revealing that it's the
things that matter. UNRESOLVED
small problems cause big ones. We need to be learning
MUCH MORE from our unresolved
small problems. What is causing our small problems.
Even more, what is it about OURSELVES that allows unresolved
small problems to exist?
It's okay to START by
performing root cause analyses on large problems so that you can discover the tie
between unresolved small problems and large problems. But
ONLY doing root cause analyses
on big problems
will assure that you will continue to have big problems.
Eventually, you need to do root cause analyses (or Failsafe's brand:
Latent Cause Analysis™)
on your unresolved small
problems. This means that EVERYONE
will need to be involved, because we ALL
have unresolved small problems.
your organization have a PLAN for involving EVERYONE in learning
from things that go wrong?
If not, you are spinning your wheels.
address safety, equipment, environmental,
and quality problems, clients include ConocoPhillips,
EI Dupont, Eastman Chemical, Voridian,
Thiokol, Petrozuata, University of
Dayton, Sun Oil, Epsilon Products,
Willamette Paper, Shell Canada, Shell US,
NASA, Department of Defense, Glow Enterprises, NewGen,
Ameriven, Sincor, Terra Industries, Suncor, Penn Maritime, and