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The 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. 

You have to know what you are looking for if you are going to find it with Root Cause Analysis.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 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 emerge.

 

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?

and most importantly:

  • What is it about the way I am that influenced these people, and what am I 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

 

More about C. Robert Nelms and Root Cause Analysis

Who is Failsafe Network?

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.

Are you ready to look at yourself in a mirror with Root Cause Analysis?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."

You are winding yourself into a ball if your Root Cause Analysis effort is not looking at yourselves!Whereas 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.

Please 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, and Australia

 

Root Cause Analysis is for EVERYONE!

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 Root Cause Analysis efforts ought to be revealing that it's the SMALLIt's the SMALL stuff that matters! 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.

EVERYONE needs to be involved in Root Cause Analysis or you will be spinning your wheels!Does your organization have a PLAN for involving EVERYONE in learning from things that go wrong?

If not, you are spinning your wheels.

 

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

Failsafe Network, Inc.

PO Box 119, Montebello, Virginia 24464

540-377-2010 voice; 540-377-2009 fax

 

email: bob@failsafe-network.com