A question came up recently in one of our Cause Mapping® workshops:
How do you keep management from influencing the outcome of root cause analysis?
The integrity of an RCA depends on staying objective and sticking to the facts. When pressures from leadership creep in, they can unintentionally—or sometimes, deliberately—shape the investigation’s findings, leading to inaccurate conclusions.
In this blog, I’ll share a real-world example that highlights how easily an incident investigation can be skewed, and what you can do to keep your analysis honest and effective.
Covering Up the Facts with an Outdated Policy
An employee was driving a company vehicle home from a job site when a motorcycle hit him. He reported the incident immediately and exactly as prescribed.
Later, he was surprised to find the incident report concluded he was at fault for “not following procedure.” When he asked what procedure he had violated, he was shown a policy forbidding employees from taking vehicles home from job sites and not returning them to the office. The problem? In ten years of service to the company, he had never seen this policy. In fact, it was commonplace for project managers to travel directly from home to the job site.
Assigning blame to the employee served to protect the company’s reputation more than it addressed the actual issues in the vehicle use process. Knowing the policy was outdated, the employee repeatedly challenged the investigation findings. Eventually, the official report’s conclusion was quietly changed from “procedure not followed” to “inadequate communication.”
How to Stay Objective When Pressures Mount
This story is a reminder that investigation findings can easily be influenced by leadership pressures, whether they come from ulterior motives or the natural tendency to jump to conclusions. Staying objective takes effort and discipline. Here are my tips to maintain clarity and avoid assumptions.
Stick to the evidence.
Base conclusions strictly on verifiable information, not on speculation or guesswork.
Go straight to the source.
Don’t rely solely on written reports. Talk directly with the people who experienced the event.
Understand the physical context.
Visit the scene or work with someone who was present to create accurate diagrams that clarify what actually happened.
Use the Cause Map™ diagram to guide discussions.
Visualizing cause-and-effect relationships keeps the investigation focused and structured.
Listen carefully without rushing to interpret.
Allow everyone involved to share their perspective fully before drawing conclusions.
Document everything in the Cause Map diagram.
Record all evidence and rationale, including reasons for ruling out possible causes.
Avoid vague explanations.
Be precise about what went wrong and why, instead of relying on broad labels like “procedure not followed.”
Consider an independent facilitator.
Someone neutral can help prevent internal pressures from influencing outcomes.
As the story shows, another key to staying objective is to examine procedures closely and carefully. Don’t assume procedures are accurate or thorough. Ask the employee to walk you through the steps they took, then compare this information to the procedure that was in use at the time of the event. Creating a process map can help clarify where gaps or disconnects exist between practice and policy.
When you compare how work is actually done in the field to what the procedure says, inconsistencies often emerge. You might find that certain steps are vague, missing, or open to interpretation. In one case, a supervisor insisted that an employee failed to follow procedure because a task wasn’t completed in the first two hours of the shift—even though the written procedure only required the task to be done once per day. These kinds of mismatches highlight how easily assumptions can mislead an investigation. By grounding your analysis in current, specific, and verifiable steps, you help shift the investigation away from blame and toward real system improvements.
Credibility Beats Convenience Every Time
When investigations are influenced by pressure to reach a specific conclusion—or to reach a conclusion as soon as possible—the entire process loses credibility. It can create a culture of blame, where people feel targeted instead of supported. This “gotcha” mindset damages morale and discourages people from sharing honest feedback in the future. It shifts attention away from improvement and toward defending against fault.
Credible investigations, on the other hand, foster a culture of learning. They use evidence to uncover what really happened and why, leading to meaningful changes that reduce risk and prevent mistakes.
In the case of the company vehicle incident, the employee’s persistence forced a correction in the official findings. But it took multiple challenges and time for the facts to come out. Had the investigation been committed to fact-based analysis in the first place, the process would have been more efficient, fair, and valuable to the company.
RCA is a powerful tool. To harness its potential, we must resist shortcuts, manage outside influences, and ensure every investigation prioritizes accuracy over convenience.
