I do not like the phrase Root Cause Analysis. It brings forth visions of a sophisticated tool used by an elite group to tell someone else why something went wrong. This vision of RCA is archaic.

I have a different vision of RCA. It is a way of seeing life, not just a tool! It is increasingly introspective, where people start by looking at other people’s problems but end-up seeing themselves as part of the causes. It looks at past events, and even uses past tense to describe their causes – but then suddenly and shockingly reveals things that are in the present, continuing to cause problems. It begins by looking at catastrophic events, but ends-up looking at the small things that cause the big ones. In the beginning, only a few people are doing RCA’s. In the end, the whole organization is thinking RCA’s.

Whereas the archaic vision was sufficient for the past, it will assure your demise if you cling onto it in the future. This is because today’s world is increasingly demanding of business and industry. Injuries and pollution are increasingly unacceptable. Unethical behavior is putting people into jail. The stockholders are continually looking for the best return on investment. In other words, you are being required to do much more with much less.

As you continue to creep closer to the “edge,” it has become increasingly necessary to understand yourselves and your businesses to a much deeper degree than ever. Approaching the edge without understanding yourselves will cause you to fall over the edge, because everything that goes wrong is because of a “lack of understanding” about ourselves!

As you will see if your read the NPRA paper, I tried to demonstrate the personal nature of vision by talking about my own home. I used the MIRACLE QUESTION to help me envision the way I'd like things to be (see paper for the MIRACLE QUESTION). The following is my vision of Root Cause Analysis within my HOME:

My family understands that unresolved small problems cause big problems. Therefore, there is a continuous attempt BY ALL OF US to fix problems as soon as they occur, and to LOG any problems that have not been immediately resolved (so that we do not forget about them). When we scratch one off (because it has been resolved), we aggressively try to find something else to add

Nevertheless, when the inevitable things go wrong in my household, we all sit down and make a sincere effort to understand:

• What were the mechanics (or the physics) of the problem. When we do not know, we find someone who does.
• What did EACH OF US do (or not do) that contributed to this problem? We start as far back (in time) as possible, and work forward with our questioning. We all contribute in an understanding, non-threatening way.
• What about the way we (as a family ARE (in general) contributed to the above actions (or inactions)?
• What are we going to do to make sure these kinds of things do not happen again?

Because of these continuing efforts, the problems we address are becoming smaller and smaller.

PS: We're not there yet, but now we know where we're going!

As many of you know, I have had a vision of a Root Cause Mother-Source for many, many years. I will not give up on this vision. Finally, it seems to be taking hold. Interestingly, it is taking hold best within organizations who are new to Root Cause Analysis. I suppose they have no biases, and no reason to question the value of such a group. These new efforts are already laps ahead of most that I've been working with for decades because they have embraced the idea of a Mother-Source.

The Root Cause "Mother-Source" is a passionate, dedicated, and trained resource focused on ingraining a root cause mentality within EVERYONE in an organization. It is called MOTHER-source because it is a nurturing entity. If the infant idea of everyone having a root cause mentality is to live, it must be nurtured. The development of this resource is the single most important thing an organization can DO to begin their Root Cause Analysis journey. With a Mother-Source, you will see progress. Without this resource, you will stagnate.

Typically each site divides itself into 5 or so geographic or functional areas. Each area appoints a Mother-Source. This can be done formally or informally. I know of organizations where the root cause analysis effort is being driven from the bottom- up. In those cases, people agree amongst themselves who are the Mother-Source leaders in each area, without even asking for approval. They just do it and make slow, continuous progress -- much like the story of the hare and the tortoise.

Imagine each site having 5 or so Mother-Source members. One of them is picked to be the leader. If an organization has 10 world-wide sites, each site has a similar Mother-Source -- each with a leader. Each of these entities are tied-together, enabling a consistant approach to RCA, as well as a means of disseminating results!

Failsafe is establishing its Mother-Source-Central to help demonstrate the intent of a Mother- Source. It is hoped that all of you that are passionate about this subject, and who desire to make a difference in your organizations, join and participate in this email- based-support group.

Try it. If you don't like it, drop-out. But if you are responsible for Root Cause Analysis, either at your site or for your whole corporation, and do NOT take part in this dialogue you are doing yourself and your organization a disservice.

The phrase "root cause" is very misunderstood and abused. Has anyone ever heard of a satisfactory definition of that phrase? Have you ever seen "root cause" defined in a report or newspaper article and said to yourself "that's not root cause!" If there is an answer to the question "why does that exist," then whatever you said was "root cause" is NOT root cause!

I have been getting increasingly bolder about this issue in my training classes. I suggest that people should NEVER, EVER use the phrase "root cause," unless they are talking about Adam and Eve (or the beginning of time). With a little thought, you will see the truth of this. Take any failure and keep asking why. You will find yourself going farther and farther back in time. Today's existance was built on yesterday's existance.

But we cannot do anything about "yesterday." We can only take what we have been handed and do our best to make it better. In terms of Root Cause Analysis, this means that we do NOT want to define Root Cause. Doing so will point us at things that happened a long time ago -- things beyond our control.

Over this next year, Failsafe will be slowly but surely changing all occurrences of the phrase "root cause analysis," and "RCA," to LATENT CAUSE ANALYSIS, and LCA. I have already changed all web-based training sessions, and will begin changing on-site sessions shortly. Thank you to all who have encouraged me to do this!

Some of you might ask, "what is Latent Cause Analysis?" Well, Latent Cause Analysis helps the RIGHT people answer the CRITICAL question:

What about the way I AM contributed to this incident, and how do I need to change in the future?

Think about it. You'll see where this could go!