Why Failsafe changed the name of our Root Cause Analysis Process

What is Root Cause Analysis?

Highlights of Failsafe’s formative root cause analysis investigative experiences included:

- Multiple explosions at Morton Thiokol's Solid Rocket Booster facilities near Ogden, Utah. Failsafe served as the "mechanical" specialist on a multi-person team led by Bendix. It was here that we discovered the difference between top-down approaches (Fault-Tree) and bottom-up approaches (Failure Modes and Effects Analysis) for analyzing systems for potential problems.

- Hazard Analysis of the Igniter Subassembly of the Solid Rocket Booster. During this 6-week study, the Space Shuttle Challenger exploded. Failsafe was on site at Morton Thiokol's production facilities during the investigation and became deeply involved in understanding why the Challenger exploded.

- A catastrophic power failure at a large chemical plant in Tennessee. Most of the interview techniques we currently use were developed during this investigation. In addition, the concept of a Translation was developed following this incident. Finally, the concept of Latency (as practiced by Failsafe) was born during this investigation. This investigation was one of the most influential of Failsafe’s formative years.

- An explosion of a hydrotreater at a Canadian Oil Sands operation. Many of the lessons shared during The Latent Cause Experience™ come from this investigation. The problem with ‘blame’ was spotlighted during this investigation. We also identified the need for evidence-based discovery, enabling people to connect the dots and see their role in an incident. A human being’s understanding is like an eggshell, and evidence is needed to crack it. This results in profound learning and an immediate change in behavior.

- A gas compressor failure at a Canadian Gas Plant that could have had catastrophic consequences. This investigation reinforced our belief that human beings cause all failure. Even more, this investigation revealed that our human tendency to try to "get away with it" is near the root of all our problems.

There are many “Root Cause Analysis” methods, procedures, and approaches on the market today. None of these methods define “root causes.” They say they do, but they do not.

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A few years ago, an 850-member forum of Root Cause Analysis professionals from all over the world, tried to define “what is Root Cause Analysis.” They could not come to a consensus! Everyone is conducting Root Cause Analysis, yet no one agrees on its definition. This present situation is absurd (at best), and deadly (at worst).

Root Cause Analysis has become whatever people want it to be.  Root Cause Analysis is no longer being taught by Failsafe because we have deemed it an overused, little-understood, and inappropriately applied phrase.

Latent Cause Analysis™ is Failsafe's version of Root Cause Analysis. LCA's are performed on any size of events. The rigor of the investigation is commensurate with the consequences. By definition, they always involve evidence-gatherers, stakeholders, and always define Physical, Human, and Latent Causes. Latent Cause Analysis™ requires people to consider one fundamental question:

"What is it about the way I am that contributed to this event?"

The answer to this question is a Latent Cause. Latent Causes are spoken admissions made by the people who contributed to the incident and answer the question: "What is it about the way I am that contributed to this incident?" This is exactly what needs to change to avoid future problems, since people cause problems, then people must change. The only healthy way to change people is to present the evidence so they see their part and need to change, then they change. Evidence or truth changes people.

In Summary, there is a problem with Root Cause Analysis these days. The problem is that it focuses on everything except “root causes.” We are the root causes of our problems. It is not our equipment, systems, society, or culture. We, each of us – all of us – are the root causes of our problems. This does not mean we should return to the practice of blaming one another for things that go wrong. On the contrary, our investigative endeavors should help one another be introspective, connect the dots, and see how we played a part in what went wrong. When we see our part, then we can change. Latent Cause Analysis is a proven process that achieves these goals.

Imagine a world where everyone would look at themselves and learn rather than pointing

fingers at others.