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The
Problem with Root Cause Analysis |
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What is a "root
cause?" An
800 person forum comprised of RCA 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
RCA 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 be traced back to the
beginning of time.
 Because
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"
differently. The
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 our problems, that is all you will see.
RCA has become whatever
people WANT it
to be, and THAT is a PROBLEM! |
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Latent Cause Analysis |
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Latent Cause
Analysis is an approach developed by Failsafe to counter the vague,
open-ended, often trivial exercise fallaciously labeled as "root
cause analysis." Is is an intensely
evidence-based endeavor designed
to help the right people discover how their behavior
contributed to an incident, to such an extent that their behavior
will change in the future.
Latent Cause Analysis is Failsafe's version
of Root Cause Analysis.
Latent Cause Analysis requires the
right people to answer the
following questions, after having reviewed the evidence:
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What were the
Physics of the Incident?
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Who Did What
Wrong (no names) to trigger the Physics?
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What is it about the
way we are that influenced these people?
and most
importantly:
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Latent Cause Analysis has been life-changing to
many who have taken the journey. |
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Welcome
 Hello.
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
besides themselves.
 As
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."
 Beware
of such approaches. They will wind you into a tighter and tighter ball
from which it will be almost impossible to SEE the truth. WE are the
causes of our problems -- each of us! Any RCA approach that does not
help people LOOK AT THEMSELVES IN A MIRROR
is, in itself, a significant cause of our problems.
Please
read-on about Failsafe's way of doing Root Cause Analysis, called
LATENT CAUSE ANALYSIS. We think you'll like it.
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From the Blue-Ridge Mountains in
Virginia, but active world-wide: United States, Canada,
England, Netherlands, Spain, Venezuela, Thailand, and Indonesia |
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Root Cause Analysis is
for EVERYONE! |
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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
wrong.
Your RCA's ought to be revealing that it's the
SMALL
things that matter. UNRESOLVED
small problems cause big ones. We need to be learning
MUCH MORE from our unresolved
small problems. What is it about OURSELVES that allows unresolved
small problems to exist?
It's okay to START by
investigating large problems so that you can discover the tie
between unresolved small and large problems. But
ONLY investigating big problems
will assure that you will continue to have big problems.
Eventually, you need to begin looking at your unresolved small
problems. This means that EVERYONE
will need to be involved, because we ALL
have unresolved small problems.
 Does
your organization have a PLAN for involving EVERYONE in learning
from things that go wrong?
If not, you are spinning your wheels. |
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Helping organizations
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
Syncrude Canada |
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