An effective Root Cause Analysis requires only three simple steps.
Define the Problem
Identify Best Solutions
This appears easy enough, but unfortunately seems to be fairly challenging for most organizations. Much of the pain and suffering is self-afflicted as we tend to over-complicate our problem solving approach. While I could speak to many of the common challenges problem solvers face, today I am going to focus on three classic root cause analysis pitfalls. I'll highlight one pitfall within each of the basic problem solving steps listed above and provide a strategy to avoid it.
Pitfall 1: The problem with the word "problem"
Charles Kettering once stated that "a problem well stated is a problem half-solved". The challenge is that everyone involved has a different perspective on defining the problem. Just ask a cross departmental team to define a problem and watch them debate what the "real" problem is. Not only does this waste time but it can also derail the problem solving effort as others will continually want to circle back to try and better define their problem.
TIP: Define the problem in terms of the organization goals.
Fortunately, this is an easy trap to avoid. First, we must remember that a "problem” is a subjective label that can be attached to anything negative. A problem for one person may be an opportunity for another. If a lion eats a gazelle, is that a problem? It depends on perspective. For the gazelle, clearly it’s a problem. The lion, not so much. Fortunately, organizational goals are aligned to achieve an end result. Therefore, problems must be defined in the context of the organizations goals.
What is your goal for Safety?
Ask anyone what your Safety goal is and you will get a consistent response. It's zero injuries. Ask anyone how much downtime we want on a daily basis and the answers will always be the same. Your organizational goals describe the ideal state, therefore, anything that impacts a goal is clearly a problem. Defining the problem in terms of the organization goals will help by removing subjectivity of the individual perspective and focus on objective representation for why the problem is important to the organization.
Pitfall 2: The allure of complexity within your problem solving approach
As human beings, we have a tendency to unnecessarily complicate things. Nothing exemplifies this more than the complexity seen within a company's approach to problem solving. Their assumption is that problems are complicated, so their approach to solving them must be as well. This couldn't be further from the truth. One of the many examples of unnecessary complexity centers around the terminology and labels that's imposed on the investigation. I'm referring to terms like contributing cause, latent cause, direct cause, indirect cause, and causal factor to name a few. To use the terms you must first define their meaning. Once again, subjectivity will come into play. For example, try asking others to distinguish whether something is a direct or indirect cause. Think you will get agreement? You will find the majority of the focus during the investigation will be centered around which cause to use versus simply explaining why the problem happened.
Tip: Dodge the terminology and focus on the fundamental principle of cause-and-effect.
Instead of labels, apply the basic principle of cause-and-effect. A cause is defined as the producer of an effect. If you validate causes with evidence, the basis of the scientific method, then it doesn't matter what "type" of cause it is. If the cause is related to the incident, then you have exposed an opportunity to prevent the problem by controlling the cause (possible solution). Applying this basic principle of cause-and-effect will help reveal an entire system of causes required to produce the problem and as a result, multiple opportunities to solve it.
Pitfall 3: Implementing EVERY solution revealed during an investigation
One of the benefits of revealing a system of causes, as described above, is the vast amount of opportunities/solutions that you expose. With this, however, comes the potential to over-solve a problem. You might be thinking.... is it really possible to over-solve a problem. There will be a point where the added benefit of each solution diminishes, known as the law of diminishing returns. Since solutions require resources, costs, and time to implement there will be a point where the benefit doesn’t outweigh the costs. This is why the Risk Curve flattens as you add more solutions.
Tip: Remind everyone that we don't have to control all of the causes.
Focus on the best solutions that get us to an acceptable level of risk. It is important during solution evaluation to make sure that everyone involved understands that the beauty of a systems approach to problem solving as described above is that we don't have to control all of the causes. In fact, in many cases, we are able to reveal simple, low cost solutions that are effective at reducing risk. I find that by making a point around this additional criteria gives others the confidence to push back on solutions that aren't worth the effort. After all, focusing our time and energy on only the "best" solutions will still adequately reduce the risk of similar problems in the future and free up your resources to solve other problems within your organization.