Let’s Get The Dirt On Root Cause Analysis

by Dave Collins on June 7, 2016

in Accidents and Incidents,Investigation,Wicked Problems



Let’s Get The Dirt On Root Cause Analysis

3d image root cause issues concept word cloud background

It has been said that our seduction with the notion of root cause analysis has done more damage to safety and risk that anything else – there is likely never going to be a definitive root cause for anything – and how far back do we go – do we just keep going until time and money run out? (check out the new video below)

One of our readers, Adam Johns, just posted an awesome question on our Topic Suggestions page. I was once a big fan of root cause analysis and wrote about it in this now embarrassing blog post a few years ago. There are very few things in safety more simplistic, biased and subjective than root cause analysis. I can understand the attraction.  However, what is not always appreciated is that, due to the interdependency of various systems and their components upon each other, initiatives may correct one problem but displace the problem elsewhere in another unanticipated form “These problems of interdependency can be referred to as messes”. (Hancock and Holt, Tame, Messy and Wicked Problems in Risk Management 2003). Band-aid or simplistic solutions implemented to address root causes, in the hope of solving a wicked problem, will almost always result in unexpected by-products and trade-offs.

Here is a new Video Released along with the new book Risky Conversations, The Law, Social Psychology and Risk

21. ROOT CAUSE from Human Dymensions on Vimeo.

I hope that our awesome authors and readers will chime in with some “sensible words”. Adam writes:

I’d like to hear some thoughts on the concept of ‘Root Cause’. In my world of aviation safety, 100+ years of accident and incident investigation has taught us that accident chains are not linear and it takes multiple ‘failures’ (sic) in a system to lead to a serious occurrence. However, some in my field continue to talk about root cause as a reliable and useful metric to capture, especially when considering non-conformances.

One simple example I’ve come across in my work to help explain Root Cause to auditors is that if the TV remote control isn’t working then the root cause is ‘Batteries not replaced’. Surely this is BS?! Most root cause analyses I’ve seen are very process and procedure driven and do not get down to how individual human and social dynamics may have resulted in the non-conformance or occurrence. But as an auditor or investigator can you ever get down to this level of detail? So many questions!

Some sensible words on this topic to help me explain the flaws in root cause to my peers would really help! I’m also interested in hearing any views in support of root cause. Always open minded!

Some recent articles on Root Cause Analysis:

Just Get to the Bottom of it

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Just Get to the Bottom of it….. Guest Post by Rob Sams from Dolphin Safety Solutions. I enjoyed meeting and chewing the fat with Rob over breakfast this morning. A great bloke who really gets what real safety and risk is all about! An incident occurs at work, the well entrenched procedures quickly kick into play – …… Read the rest of the article

 

Is the Safety Function Focusing On the Wrong Things?

image_thumb.pngOut of Focus: Is the Safety Function Focusing On the Wrong Things?   By Phil La Duke on his blog http://philladuke.wordpress.com/ Phil says: In this week’s post I identify three areas that the safety profession has been obsessing on, and ask the question have we been focused on the wrong things for …… Read the rest of the article

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