John Wooden was the basketball coach of the UCLA Bruins for 27 years, from 1948 to 1975. In his last 12 seasons at UCLA the Bruins won 10 NCAA Championships. Winning one NCAA championship is a significant accomplishment. There was a period in those twelve seasons that the UCLA Bruins won seven consecutive championships, from 1967 to 1973. They had 4 different undefeated seasons of 30-0. At one point, the Bruins won 88 consecutive basketball games. His coaching record at UCLA was 620-147 (.808 winning percentage). ESPN has referred to John Wooden as the greatest coach of all time, not just in basketball, but in any sport.Each year some of the best high school players in the nation would begin their college career at UCLA. These players already knew how to dribble, pass and shoot. But John Wooden assumed nothing. Every year he started with the basics, including how to properly put on socks and shoes. ESPN interviewed Coach Wooden and asked him “Is it true that you used to instruct your players on how to put on their shoes and socks before each game or practice?” This was Coach Wooden’s response:
“Absolutely; I picked that up when I was teaching in high school. We had a lot of blisters, and I found out that a lot of the players didn’t smooth out all the wrinkles around their heels and around their little toes, places where the blisters are apt to occur. Then I found out that they didn’t lace their shoes properly and oftentimes they wore shoes that were a size too large. With all the quick-stop turning, changes of direction, changes of pace on a hard floor you have in basketball, this would cause blisters. So, I thought it was very important that I’d check their shoe size and how they put their socks on. I hoped they would take a few extra seconds to smooth out the wrinkles around the heel and the toes and hold the sock up while they put their shoe on. I think it was important. And I know from the time I started in high school that we greatly reduced the number of blisters that we’d have, so I continued that throughout my coaching. I know a number of players laughed about it. They probably still laugh about it now. But I stuck to it. I think to some degree it helped team unity. I believed in that and I insisted on it.”
This was John Wooden’s approach to putting socks on your feet. Socks?! Do you think he had strong views on the mechanics of a free throw? A root cause analysis on UCLA’s championships shouldn’t conclude that putting socks on properly is the cause. But it is one of the causes. There wasn’t one thing that John Wooden did, there were many. They included socks and free throws and passing and dribbling and shooting. It was all of them. It was the combination of things, each of which on their own is no big deal, but all of them together produced the results.This is exactly how every success and problem occurs within your organization. There isn’t one cause, there are always causes. Any one of the causes on its own is no big deal, but all of the causes together are exactly what produces the results. Does this statement sound familiar in your organization? “It’s amazing how everything happened just the way it needed to for the problem to occur.”
People naturally try to attribute a given incident (good or bad) to one cause, but it’s always the combination of causes that produces the effect. It’s always the system. This simple concept gives us amazing leverage because we only have to control a few selected causes to prevent the entire incident. This fundamental point is normal practice within highly reliable organizations. Since all of the causes are required to produce an effect, each cause doesn’t have to be solved to change that effect. When people talk about “breaking the chain of events,” the chain can be broken anywhere.
This is the simplicity of root cause analysis that unfortunately gets missed. Organizations distort a basic concept into a misguided search for the single “root cause,” the one thing that created the effect. This mentality actually feeds disagreements and creates confusion (maybe you’ve see people argue about who’s right in your problem discussions). Coach Wooden provides a valuable reminder that it’s always about the basics. Don’t make it too complicated. Incredible results never bypass the basics.
There are two points in this story about Coach Wooden that relate to the basic concepts of root cause analysis and high reliability organizations.
1) It’s not the one thing. It’s always the combination of the things. On their own they may seem like “no big deal,” but together they produce the effect. This is why people mistakenly use the term contributing factor or contributing cause to a less important cause – something that, on its own, can’t produce the issue. There are just causes. The term contributing cause is actually redundant.
2) Don’t assume anything. How specific are the training programs within your company? What do your work processes assume as “skill of craft?” Are there problems in these areas? How clear do you want the tasks that are important to your business? Ask the people who do the work to share the details of what they do. Are there gaps between what the experienced people actually do and what the procedures state? Get insight from those that do the work. Find out what the original designers say. The people closest to the work clarify the necessary level of detail. Problems don’t happen because tasks were too clear.
For more information about improving the reliability of your organization by understanding how to apply effective root cause analysis to your problems and processes contact or office or attend one of our Cause Mapping workshops.
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